Provider Demographics
NPI:1063739175
Name:WANG, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8901 ACTIVITY RD
Mailing Address - Street 2:STE 103
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-4436
Mailing Address - Country:US
Mailing Address - Phone:619-752-0001
Mailing Address - Fax:
Practice Address - Street 1:353 W 9TH AVE
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-5032
Practice Address - Country:US
Practice Address - Phone:619-714-9100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-28
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1375582085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology