Basic Information
| Provider Information | |||||||||
| NPI: | 1457615395 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WANG | ||||||||
| FirstName: | CHIACHIEN | ||||||||
| MiddleName: | JAKE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1684 | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711651684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184244088 | ||||||||
| FaxNumber: | 8552301466 | ||||||||
| Practice Location | |||||||||
| Address1: | 2600 KINGS HWY | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711033950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182124639 | ||||||||
| FaxNumber: | 3182128305 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2012 | ||||||||
| LastUpdateDate: | 04/27/2018 | ||||||||
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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 | 390200000X | CT | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 390200000X | BP10047559 | TX | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2085R0001X | 304912 | LA | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
No ID Information.