Basic Information
| Provider Information | |||||||||
| NPI: | 1578698874 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROBERT T. WANG, PH.D., M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5901 W OLYMPIC BLVD | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900364667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3239313100 | ||||||||
| FaxNumber: | 3239310030 | ||||||||
| Practice Location | |||||||||
| Address1: | 5901 W OLYMPIC BLVD | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900364667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3239313100 | ||||||||
| FaxNumber: | 3239310030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2007 | ||||||||
| LastUpdateDate: | 09/30/2011 | ||||||||
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| AuthorizedOfficialLastName: | WANG | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3239313100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PH.D., M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | G40989 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 9745630 | 05 | CA | MEDICAID | GR0079630 | 05 | CA | MEDICAID |