Provider Demographics
NPI:1962614388
Name:WANG, JIM (DO)
Entity type:Individual
Prefix:
First Name:JIM
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:PO BOX 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:702-877-5199
Mailing Address - Fax:
Practice Address - Street 1:2210 E CALVADA BLVD
Practice Address - Street 2:
Practice Address - City:PAHRUMP
Practice Address - State:NV
Practice Address - Zip Code:89048-5804
Practice Address - Country:US
Practice Address - Phone:775-727-6400
Practice Address - Fax:775-727-7543
Is Sole Proprietor?:No
Enumeration Date:2007-05-06
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV907207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVP00928524OtherRR MEDICARE
NV1962614388Medicaid
NVEP085YMedicare PIN
NV1962614388Medicaid