Provider Demographics
NPI:1023174901
Name:WANG, THERESA (MD)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:WANG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2795 PEACHTREE RD NE
Mailing Address - Street 2:#309
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-3611
Mailing Address - Country:US
Mailing Address - Phone:718-672-2824
Mailing Address - Fax:
Practice Address - Street 1:1218 W PACES FERRY RD NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-2308
Practice Address - Country:US
Practice Address - Phone:404-480-4888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT188087208200000X
GA70000208200000X
GA0700002086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery