Basic Information
| Provider Information | |||||||||
| NPI: | 1457336539 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WANG | ||||||||
| FirstName: | JUN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11535 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468591535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175672180 | ||||||||
| FaxNumber: | 3175672191 | ||||||||
| Practice Location | |||||||||
| Address1: | 10351 DAWSONS CREEK BLVD | ||||||||
| Address2: | STE D | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468251904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2609691950 | ||||||||
| FaxNumber: | 2609690989 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2005 | ||||||||
| LastUpdateDate: | 11/06/2008 | ||||||||
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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 | 207L00000X | 01060887 | IN | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 200850020 | 05 | IN | MEDICAID |