Provider Demographics
NPI:1902367766
Name:WANG, KEVIN (DO)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:WANG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2834
Mailing Address - Country:US
Mailing Address - Phone:217-223-1200
Mailing Address - Fax:
Practice Address - Street 1:1005 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2834
Practice Address - Country:US
Practice Address - Phone:217-223-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2025-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022004128207R00000X
MO2019021744207R00000X, 208000000X
MI5101027375207R00000X
IL036175383207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics