Provider Demographics
NPI:1154353126
Name:WANG, JIN (MD)
Entity type:Individual
Prefix:
First Name:JIN
Middle Name:
Last Name:WANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1869
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91785-1869
Mailing Address - Country:US
Mailing Address - Phone:909-981-5882
Mailing Address - Fax:909-373-2828
Practice Address - Street 1:1317 W FOOTHILL BLVD
Practice Address - Street 2:STE 148
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-3676
Practice Address - Country:US
Practice Address - Phone:909-981-5882
Practice Address - Fax:909-946-0833
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA49349207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A493490Medicaid
CAF27763Medicare UPIN
CA49349Medicare ID - Type Unspecified