Provider Demographics
NPI:1780061671
Name:WANG, SKY
Entity type:Individual
Prefix:
First Name:SKY
Middle Name:
Last Name:WANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:TIANYI
Other - Middle Name:
Other - Last Name:WANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1200 N STATE ST
Mailing Address - Street 2:CT-A7D
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-1029
Mailing Address - Country:US
Mailing Address - Phone:323-226-7556
Mailing Address - Fax:323-226-2657
Practice Address - Street 1:1200 N STATE ST
Practice Address - Street 2:CT-A7D
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-1029
Practice Address - Country:US
Practice Address - Phone:323-226-7556
Practice Address - Fax:323-226-2657
Is Sole Proprietor?:No
Enumeration Date:2015-04-30
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA144810207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASW3232267556Medicaid