Provider Demographics
NPI:1982647939
Name:WU, JIMMY (MD)
Entity Type:Individual
Prefix:DR
First Name:JIMMY
Middle Name:
Last Name:WU
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 1:12751 HARBOR BLVD
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-5800
Mailing Address - Country:US
Mailing Address - Phone:714-636-7852
Mailing Address - Fax:
Practice Address - Street 1:12751 HARBOR BLVD
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-5800
Practice Address - Country:US
Practice Address - Phone:714-636-7852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2011-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA-49571207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0083450Medicaid
CAW13845Medicare ID - Type Unspecified
CAGR0083450Medicaid