Provider Demographics
NPI:1306980107
Name:WONG, BUU KIM (DPM)
Entity type:Individual
Prefix:
First Name:BUU
Middle Name:KIM
Last Name:WONG
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:BUU
Other - Middle Name:KIM
Other - Last Name:WONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:500 E CARSON ST
Mailing Address - Street 2:STE 112
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745-2713
Mailing Address - Country:US
Mailing Address - Phone:310-518-3972
Mailing Address - Fax:310-518-3998
Practice Address - Street 1:500 E CARSON ST
Practice Address - Street 2:STE 112
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90745-2713
Practice Address - Country:US
Practice Address - Phone:310-518-3972
Practice Address - Fax:310-518-3998
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2351213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWE2351AMedicare PIN
CAT11300Medicare UPIN