Provider Demographics
NPI:1063516409
Name:WANG, OLIVER (DPM)
Entity type:Individual
Prefix:DR
First Name:OLIVER
Middle Name:
Last Name:WANG
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:268 N MAR VISTA AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-5314
Mailing Address - Country:US
Mailing Address - Phone:818-848-5583
Mailing Address - Fax:818-848-1872
Practice Address - Street 1:241 W OLIVE AVE
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91502-1825
Practice Address - Country:US
Practice Address - Phone:818-848-5583
Practice Address - Fax:818-848-1872
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4275213ES0103X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE4275AMedicare PIN
CAU90300Medicare UPIN