Provider Demographics
NPI:1124887625
Name:WANG, THEODORE
Entity type:Individual
Prefix:
First Name:THEODORE
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 1:2700 SW ARCHER RD APT E21
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-1329
Mailing Address - Country:US
Mailing Address - Phone:321-216-1480
Mailing Address - Fax:
Practice Address - Street 1:200 W ARBOR DR # MC8425
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-1911
Practice Address - Country:US
Practice Address - Phone:619-543-6268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program