Provider Demographics
NPI:1487837043
Name:CONNIE WONG, DPM AND KI SANG YI, DPM INC.
Entity Type:Organization
Organization Name:CONNIE WONG, DPM AND KI SANG YI, DPM INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TIV
Authorized Official - Middle Name:
Authorized Official - Last Name:BUNLEUTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-234-3174
Mailing Address - Street 1:1703 TERMINO AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-2126
Mailing Address - Country:US
Mailing Address - Phone:562-597-5100
Mailing Address - Fax:562-597-5165
Practice Address - Street 1:1703 TERMINO AVE STE 103
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-2126
Practice Address - Country:US
Practice Address - Phone:562-597-2100
Practice Address - Fax:562-597-5165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-06
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4250213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1295746345OtherNPI
CA1033120118OtherNPI
CA1295746345OtherNPI