Provider Demographics
NPI:1578556742
Name:BOLLMANN, WONSIK Y (DPM)
Entity Type:Individual
Prefix:DR
First Name:WONSIK
Middle Name:Y
Last Name:BOLLMANN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15366 11TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-3726
Mailing Address - Country:US
Mailing Address - Phone:760-951-1234
Mailing Address - Fax:760-951-1611
Practice Address - Street 1:15366 11TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-3726
Practice Address - Country:US
Practice Address - Phone:760-951-1234
Practice Address - Fax:760-951-1611
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2017-01-09
Deactivation Date:2006-03-27
Deactivation Code:
Reactivation Date:2006-04-12
Provider Licenses
StateLicense IDTaxonomies
CAE3966213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E39660Medicaid
CA000E39660Medicaid
CA000E39660Medicare PIN
CAU55046Medicare UPIN