Healthcare Provider Details

I. General information

NPI: 1578906186
Provider Name (Legal Business Name): KEVIN THIEN TOAN BUI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2013
Last Update Date: 07/14/2022
Certification Date: 07/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 GROSSMONT CENTER DR
LA MESA CA
91942-3019
US

IV. Provider business mailing address

7777 ALVARADO RD STE 108
LA MESA CA
91942-8245
US

V. Phone/Fax

Practice location:
  • Phone: 619-740-5100
  • Fax:
Mailing address:
  • Phone: 619-460-2770
  • Fax: 619-460-2774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberA134576
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: