Provider Demographics
NPI:1326186073
Name:WANG, JONATHAN I (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:I
Last Name:WANG
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:10151 YORK ROAD
Mailing Address - Street 2:120
Mailing Address - City:COCKEYSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21030
Mailing Address - Country:US
Mailing Address - Phone:888-481-9185
Mailing Address - Fax:888-481-9421
Practice Address - Street 1:713 W DUARTE ROAD
Practice Address - Street 2:G195
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91004
Practice Address - Country:US
Practice Address - Phone:310-923-5362
Practice Address - Fax:360-361-3400
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2008-02-28
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Provider Licenses
StateLicense IDTaxonomies
CAA75879173000000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH76989Medicare UPIN
CAA75879Medicare ID - Type UnspecifiedPROVIDER NUMBER