Provider Demographics
NPI:1942615646
Name:WANG, ELISA MARIE CRYSTAL (MD)
Entity type:Individual
Prefix:DR
First Name:ELISA
Middle Name:MARIE CRYSTAL
Last Name:WANG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ELISA
Other - Middle Name:MARIE
Other - Last Name:CRYSTAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:201 E GREEN ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-5635
Mailing Address - Country:US
Mailing Address - Phone:607-274-6200
Mailing Address - Fax:
Practice Address - Street 1:201 E GREEN ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-5635
Practice Address - Country:US
Practice Address - Phone:607-274-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-23
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361462022084P0800X
NY3127162084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry