Basic Information
| Provider Information | |||||||||
| NPI: | 1104037191 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WANG | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | JEN CHU | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 849931 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752840001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2148211177 | ||||||||
| FaxNumber: | 2148211193 | ||||||||
| Practice Location | |||||||||
| Address1: | 3600 GASTON AVE | ||||||||
| Address2: | SUITE 550 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752461800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2148211177 | ||||||||
| FaxNumber: | 2148211193 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2007 | ||||||||
| LastUpdateDate: | 09/06/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | M5971 | TX | N | Allopathic & Osteopathic Physicians | Hospitalist | 207RC0000X | A104072 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 8AL360 | 01 | TX | BCBS | OTHER |