1255313631 NPI number — JAMES WANG D.O.

Table of content: JAMES WANG D.O. (NPI 1255313631)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255313631 NPI number — JAMES WANG D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WANG
Provider First Name:
JAMES
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255313631
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/01/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
907 18TH ST E
Provider Second Line Business Mailing Address:
SUITE 150
Provider Business Mailing Address City Name:
TIFTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31794-3643
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-353-3422
Provider Business Mailing Address Fax Number:
229-353-6060

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
901 18TH ST E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TIFTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31794-3648
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-382-7120
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/19/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  H0062660 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207LP2900X , with the licence number: H0062660 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: 060334 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: KK25 . This is a "MEDICARE, GROUP NUMBER" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 444354919A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 444354919B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00224353 . This is a "RR MEDICARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 407070400 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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