Provider Demographics
NPI:1326285651
Name:PHILLIP WUNDER DO INC
Entity Type:Organization
Organization Name:PHILLIP WUNDER DO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:WUNDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-860-8300
Mailing Address - Street 1:23441 GOLDEN SPRINGS DR
Mailing Address - Street 2:533
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-2030
Mailing Address - Country:US
Mailing Address - Phone:909-860-8300
Mailing Address - Fax:
Practice Address - Street 1:414 S PROSPECTORS RD
Practice Address - Street 2:STE A
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-1615
Practice Address - Country:US
Practice Address - Phone:909-860-8300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-08
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A4967207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20A4967Medicare PIN