Provider Demographics
NPI:1427115708
Name:FAN, WEN - LING LEE (MD)
Entity type:Individual
Prefix:DR
First Name:WEN - LING
Middle Name:LEE
Last Name:FAN
Suffix:
Gender:F
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 39
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039-0039
Mailing Address - Country:US
Mailing Address - Phone:973-533-1959
Mailing Address - Fax:973-214-5128
Practice Address - Street 1:305 OLDHAM RD
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-2208
Practice Address - Country:US
Practice Address - Phone:973-904-6126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA034358208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0875201Medicaid
NJ139318Medicare ID - Type Unspecified
NJ0875201Medicaid