Provider Demographics
NPI:1942282819
Name:FUNG, WILSON (MD)
Entity Type:Individual
Prefix:
First Name:WILSON
Middle Name:
Last Name:FUNG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2438 N PONDEROSA DR
Mailing Address - Street 2:BLDG C 101
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-2369
Mailing Address - Country:US
Mailing Address - Phone:805-484-1190
Mailing Address - Fax:805-764-0176
Practice Address - Street 1:2438 N PONDEROSA DR
Practice Address - Street 2:BLDG C-101
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-2369
Practice Address - Country:US
Practice Address - Phone:804-484-1190
Practice Address - Fax:805-764-0176
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG069969207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine