Provider Demographics
NPI:1962755702
Name:MICHAEL WAN, M.D., INC
Entity type:Organization
Organization Name:MICHAEL WAN, M.D., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-546-6600
Mailing Address - Street 1:11100 WARNER AVE
Mailing Address - Street 2:SUITE 150B
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-7506
Mailing Address - Country:US
Mailing Address - Phone:714-546-6600
Mailing Address - Fax:714-546-6608
Practice Address - Street 1:11100 WARNER AVE
Practice Address - Street 2:SUITE 150B
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-7506
Practice Address - Country:US
Practice Address - Phone:714-546-6600
Practice Address - Fax:714-546-6608
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MICHAEL WAN, M.D.,INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-10-17
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA36431261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA28086Medicare UPIN