Provider Demographics
NPI:1467466136
Name:WANG, HAIQIU ELAINE (MD)
Entity type:Individual
Prefix:
First Name:HAIQIU
Middle Name:ELAINE
Last Name:WANG
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 1:420 S GERMANTOWN PKWY
Mailing Address - Street 2:SUITE 105B
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-4387
Mailing Address - Country:US
Mailing Address - Phone:901-343-0180
Mailing Address - Fax:901-590-0349
Practice Address - Street 1:420 S GERMANTOWN PKWY
Practice Address - Street 2:SUITE 105B
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-4387
Practice Address - Country:US
Practice Address - Phone:901-343-0180
Practice Address - Fax:901-590-0349
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD37771207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3703214Medicaid
TNQ006833Medicaid
H64580Medicare UPIN
TN103I088269Medicare PIN