Healthcare Provider Details

I. General information

NPI: 1306980107
Provider Name (Legal Business Name): BUU KIM WONG D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: BUU KIM WONG D.P.M.

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 01/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 E CARSON ST STE 112
CARSON CA
90745-2713
US

IV. Provider business mailing address

500 E CARSON ST STE 112
CARSON CA
90745-2713
US

V. Phone/Fax

Practice location:
  • Phone: 310-518-3972
  • Fax: 310-518-3998
Mailing address:
  • Phone: 310-518-3972
  • Fax: 310-518-3998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE2351
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: