Provider Demographics
NPI:1750428173
Name:WANG, KENNETH C (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:C
Last Name:WANG
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 N WOLFE ST
Mailing Address - Street 2:DEPT. RADIOLOGY, BLALOCK 100
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21287-0005
Mailing Address - Country:US
Mailing Address - Phone:410-955-6500
Mailing Address - Fax:443-287-3622
Practice Address - Street 1:600 N WOLFE ST
Practice Address - Street 2:DEPT. RADIOLOGY, BLALOCK 100
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0005
Practice Address - Country:US
Practice Address - Phone:410-955-6500
Practice Address - Fax:443-287-3622
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00650472085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD022617300Medicaid
MD022617300Medicaid