MEDICARE: CARSON FOOT CLINIC A PODIATRIST GROUP INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213E00000X	Podiatrist	E2351	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154315034
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARSON FOOT CLINIC A PODIATRIST GROUP INC

Provider Business Mailing Address
First Line	:	500 E CARSON ST
Second Line	:	STE 112
City	:	CARSON
State	:	CA
Zip	:	90745-2713
Country	:	US
Telephone Number	:	310-518-3972
Fax Number	:	310-518-3998

Provider Business Practice Location Address
First Line	:	500 E CARSON ST
Second Line	:	STE 112
City	:	CARSON
State	:	CA
Zip	:	90745-2713
Country	:	US
Telephone Number	:	310-518-3972
Fax Number	:	310-518-3998

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. BUU KIM WONG
Credential	:	DPM
Telephone Number	:	310-518-3972

Provider Enumeration Date	:	09/07/2005
Last Update Date	:	08/22/2020

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