Healthcare Provider Details

I. General information

NPI: 1336214766
Provider Name (Legal Business Name): PHILLIP A WUNDER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 06/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 S PROSPECTORS RD SUITE A
DIAMOND BAR CA
91765-1615
US

IV. Provider business mailing address

23441 GOLDEN SPRINGS DR 533
DIAMOND BAR CA
91765-2030
US

V. Phone/Fax

Practice location:
  • Phone: 909-860-8300
  • Fax: 909-861-4090
Mailing address:
  • Phone: 909-860-8300
  • Fax: 909-861-4090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number20A4967
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: