Provider Demographics
NPI:1407986995
Name:WILVANG, GINA L (DPM)
Entity Type:Individual
Prefix:DR
First Name:GINA
Middle Name:L
Last Name:WILVANG
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 111
Mailing Address - Street 2:
Mailing Address - City:ARTESIA
Mailing Address - State:CA
Mailing Address - Zip Code:90702-0111
Mailing Address - Country:US
Mailing Address - Phone:562-402-2489
Mailing Address - Fax:562-809-7219
Practice Address - Street 1:18300 GRIDLEY RD
Practice Address - Street 2:SUITE 203
Practice Address - City:ARTESIA
Practice Address - State:CA
Practice Address - Zip Code:90701-5440
Practice Address - Country:US
Practice Address - Phone:562-402-2489
Practice Address - Fax:562-809-7219
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4393213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU90569Medicare UPIN