Provider Demographics
NPI:1699317883
Name:WANG, XIAODONG SR
Entity type:Individual
Prefix:
First Name:XIAODONG
Middle Name:
Last Name:WANG
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4844 186TH ST
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-1923
Mailing Address - Country:US
Mailing Address - Phone:718-869-3607
Mailing Address - Fax:
Practice Address - Street 1:4844 186TH ST
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-1109
Practice Address - Country:US
Practice Address - Phone:718-869-3607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-09
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031856225700000X
NY007337171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty