Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 01071171A | IN |
N | 207Q00000X | Family Doctor | MT192454 | PA |
N | 207QS0010X | Family Doctor - Sports Medicine | 01071171A | IN |
NPI | 1104086958 |
---|---|
Provider Name | Jeffrey Wang |
First Address | Muncie, IN 47303-4988 |
Second Address | Lafayette, IN 47909-6303 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/06/2008 |
Last Update Date | 01/03/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000770499 | ANTHEM FAMILY MEDICINE PIN (01) | IN |
000000824591 | ANTHEM URGENT CARE PIN (01) | IN |
201069250 | (05) | IN |