Provider Demographics
NPI:1225747421
Name:TINA W MD INC A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:TINA W MD INC A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:WU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-674-1904
Mailing Address - Street 1:425 15TH ST UNIT 3142
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-7311
Mailing Address - Country:US
Mailing Address - Phone:917-674-1904
Mailing Address - Fax:
Practice Address - Street 1:1812 11TH ST
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-6212
Practice Address - Country:US
Practice Address - Phone:917-674-1904
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-16
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty