Basic Information
Provider Information | |||||||||
NPI: | 1912418666 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WENG | ||||||||
FirstName: | JIA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 41 E POST RD | ||||||||
Address2: |   | ||||||||
City: | WHITE PLAINS | ||||||||
State: | NY | ||||||||
PostalCode: | 106014699 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9146810600 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 15000 MIDLANTIC DR STE 102 | ||||||||
Address2: |   | ||||||||
City: | MOUNT LAUREL | ||||||||
State: | NJ | ||||||||
PostalCode: | 080541573 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8557272465 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/21/2017 | ||||||||
LastUpdateDate: | 08/05/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/05/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 25MB11160300 | NJ | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207L00000X | 318232 | NY | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
No ID Information.