Basic Information
| Provider Information | |||||||||
| NPI: | 1275514937 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WANG | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 MADISON ST | ||||||||
| Address2: | 355 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802065419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033772020 | ||||||||
| FaxNumber: | 3033772022 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 MADISON ST | ||||||||
| Address2: | 355 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802065419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033987320 | ||||||||
| FaxNumber: | 3033880606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2005 | ||||||||
| LastUpdateDate: | 07/29/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | DR.0040750 | CO | Y | Allopathic & Osteopathic Physicians | Ophthalmology | 174400000X | DR.0040750 | CO | N | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 59936525 | 05 | CO | MEDICAID |