Provider Demographics
NPI:1063475242
Name:WANG, PETER C (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:C
Last Name:WANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:510 SUPERIOR AVE
Mailing Address - Street 2:STE. 200-G
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3663
Mailing Address - Country:US
Mailing Address - Phone:949-791-6767
Mailing Address - Fax:949-791-6768
Practice Address - Street 1:510 SUPERIOR AVE
Practice Address - Street 2:STE. 200-G
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3663
Practice Address - Country:US
Practice Address - Phone:949-791-6767
Practice Address - Fax:949-791-6768
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-10
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG84367208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G843670Medicaid
CAH16512Medicare UPIN
CAG84367BMedicare ID - Type Unspecified