Provider Demographics
NPI:1194737486
Name:WANG, VINCENT YUANCONG (DO)
Entity type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:YUANCONG
Last Name:WANG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:YUANCONG
Other - Middle Name:
Other - Last Name:WANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:4373 UNION ST
Mailing Address - Street 2:SUITE C-B
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-3063
Mailing Address - Country:US
Mailing Address - Phone:718-886-3877
Mailing Address - Fax:718-886-3995
Practice Address - Street 1:4373 UNION ST
Practice Address - Street 2:SUITE C-B
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-3063
Practice Address - Country:US
Practice Address - Phone:718-886-3877
Practice Address - Fax:718-886-3995
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2011-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY229200207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02641041Medicaid
NY07002Medicare ID - Type Unspecified
NY02641041Medicaid