Provider Demographics
NPI:1346731767
Name:WIGUNA, JASON SATRIA (DO)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:SATRIA
Last Name:WIGUNA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2954 ROSEMARY LN
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-4328
Mailing Address - Country:US
Mailing Address - Phone:562-508-0158
Mailing Address - Fax:
Practice Address - Street 1:12601 GARDEN GROVE BLVD
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-1908
Practice Address - Country:US
Practice Address - Phone:714-537-5160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-21
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A19069207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine