Provider Demographics
NPI:1104820950
Name:WANG, MICHAEL (OD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WANG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9727 ELK GROVE FLORIN RD
Mailing Address - Street 2:#190
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-2264
Mailing Address - Country:US
Mailing Address - Phone:916-686-5165
Mailing Address - Fax:916-686-5865
Practice Address - Street 1:9727 ELK GROVE FLORIN RD
Practice Address - Street 2:#190
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624-2264
Practice Address - Country:US
Practice Address - Phone:916-686-5165
Practice Address - Fax:916-686-5865
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT10004TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASDO100040Medicaid
CASDO100040Medicaid