Healthcare Provider Details

I. General information

NPI: 1699340687
Provider Name (Legal Business Name): KEVIN JULIUS WU DO, MBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2021
Last Update Date: 09/07/2026
Certification Date: 09/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5020 CAMPUS DR STE 210
NEWPORT BEACH CA
92660-2111
US

IV. Provider business mailing address

5020 CAMPUS DR STE 210
NEWPORT BEACH CA
92660-2111
US

V. Phone/Fax

Practice location:
  • Phone: 310-929-9790
  • Fax:
Mailing address:
  • Phone: 310-929-9790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number20A25912
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: