Provider Demographics
NPI:1366204091
Name:BANG, SALLY
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:BANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18574 FIELDBROOK ST
Mailing Address - Street 2:
Mailing Address - City:ROWLAND HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91748-4829
Mailing Address - Country:US
Mailing Address - Phone:626-905-1633
Mailing Address - Fax:
Practice Address - Street 1:7350 SW 60TH AVE STE 2
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34476-6476
Practice Address - Country:US
Practice Address - Phone:352-854-5530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-29
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9118866207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine