Provider Demographics
NPI:1457428674
Name:WANG, JIM C (MD)
Entity type:Individual
Prefix:
First Name:JIM
Middle Name:C
Last Name:WANG
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:393 E WALNUT ST
Mailing Address - Street 2:PHR GROUP PROVIDER ENROLLMENT 3RD FL
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91188-0001
Mailing Address - Country:US
Mailing Address - Phone:877-608-0044
Mailing Address - Fax:877-514-0903
Practice Address - Street 1:1 STADIUM DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26506-7900
Practice Address - Country:US
Practice Address - Phone:304-598-4820
Practice Address - Fax:304-293-6963
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2021-12-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA79074207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810009324Medicaid
WVP00416436OtherRAILROAD MEDICARE
CA00A790740Medicaid
WV3810009324Medicaid
H33008Medicare UPIN