Basic Information
| Provider Information | |||||||||
| NPI: | 1861443079 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WANG | ||||||||
| FirstName: | CHIH JEN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 211 E BROADWAY | ||||||||
| Address2: | |||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620026220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004072696 | ||||||||
| FaxNumber: | 8004326004 | ||||||||
| Practice Location | |||||||||
| Address1: | 1560 W US HIGHWAY 50 | ||||||||
| Address2: | |||||||||
| City: | O FALLON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622691619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183976575 | ||||||||
| FaxNumber: | 8004326004 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 02/14/2014 | ||||||||
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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 | 152W00000X | 046-009615 | IL | Y | Eye and Vision Services Providers | Optometrist | 152W00000X | 2004001752 | MO | N | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 046009615 | 05 | IL | MEDICAID | P00403017 | 01 | IL | RR MEDICARE | OTHER |