Healthcare Provider Details

I. General information

NPI: 1780603761
Provider Name (Legal Business Name): WILSON DUGADUGA LAO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1238 E ARROW HWY SUITE 100
UPLAND CA
91786-4951
US

IV. Provider business mailing address

11370 ANDERSON ST SUITE 3615
LOMA LINDA CA
92354-3450
US

V. Phone/Fax

Practice location:
  • Phone: 909-946-5348
  • Fax: 909-946-6598
Mailing address:
  • Phone: 909-558-2481
  • Fax: 909-558-2608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA56414
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: