Provider Demographics
NPI:1215253059
Name:JI, WANG (MD)
Entity type:Individual
Prefix:
First Name:WANG
Middle Name:
Last Name:JI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JAMES
Other - Middle Name:
Other - Last Name:JI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:12900 PARK PLAZA DR STE 150
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-9329
Mailing Address - Country:US
Mailing Address - Phone:562-977-4639
Mailing Address - Fax:
Practice Address - Street 1:10000 LAKEWOOD BLVD
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90240-4020
Practice Address - Country:US
Practice Address - Phone:562-862-3684
Practice Address - Fax:562-862-7145
Is Sole Proprietor?:No
Enumeration Date:2010-04-19
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA125738207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1902846306OtherGROUP NPI
CAGR0100430OtherGROUP MEDI-CAL
CAW18762OtherGROUP MEDICARE