Basic Information
| Provider Information | |||||||||
| NPI: | 1649204397 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WANG | ||||||||
| FirstName: | VICTOR | ||||||||
| MiddleName: | SHERWIN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PHR GROUP PROVIDER ENROLLMENT UNIT 3RD FL | ||||||||
| Address2: | 393 E WALNUT ST | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911880001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8776080044 | ||||||||
| FaxNumber: | 8775140903 | ||||||||
| Practice Location | |||||||||
| Address1: | 1050 E YORBA LINDA BLVD | ||||||||
| Address2: | #103 THE INTERNAL MEDICINE GROUP | ||||||||
| City: | PLACENTIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928703730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149963700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 11/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 227891 | MA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0100X | A86616 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | BL515 | 01 | CA | MEDICARE PTAN | OTHER |