Basic Information
| Provider Information | |||||||||
| NPI: | 1699715789 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WANG | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14023 SOUTHWEST FWY | ||||||||
| Address2: | |||||||||
| City: | SUGAR LAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774783550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2813254100 | ||||||||
| FaxNumber: | 2813254292 | ||||||||
| Practice Location | |||||||||
| Address1: | 14023 SOUTHWEST FWY | ||||||||
| Address2: | |||||||||
| City: | SUGAR LAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774783550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2813254100 | ||||||||
| FaxNumber: | 2813254292 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 12/29/2014 | ||||||||
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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 | 207Q00000X | J2408 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 116312301 | 05 | TX | MEDICAID | 116312303 | 05 | TX | MEDICAID |