Healthcare Provider Details

I. General information

NPI: 1861679979
Provider Name (Legal Business Name): WESLEY LEE FUNG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2008
Last Update Date: 06/16/2022
Certification Date: 06/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18370 BURBANK BLVD STE 607
TARZANA CA
91356-2833
US

IV. Provider business mailing address

18370 BURBANK BLVD STE 607
TARZANA CA
91356-2833
US

V. Phone/Fax

Practice location:
  • Phone: 747-265-6252
  • Fax: 747-265-6892
Mailing address:
  • Phone: 747-265-6252
  • Fax: 747-265-6892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA93327
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberA93327
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: