Provider Demographics
NPI:1043515877
Name:HOLLY WANG MD INC
Entity type:Organization
Organization Name:HOLLY WANG MD INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EZEKIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-696-1234
Mailing Address - Street 1:PO BOX 50127
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91115-0127
Mailing Address - Country:US
Mailing Address - Phone:626-696-1234
Mailing Address - Fax:626-696-1230
Practice Address - Street 1:50 ALESSANDRO PL
Practice Address - Street 2:SUITE 200
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3149
Practice Address - Country:US
Practice Address - Phone:626-696-1234
Practice Address - Fax:626-696-1230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-26
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69635208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty