Provider Demographics
NPI:1336569300
Name:BUI, ANTIEM (DO)
Entity Type:Individual
Prefix:
First Name:ANTIEM
Middle Name:
Last Name:BUI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:667 EASTLAND AVE SE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-4503
Mailing Address - Country:US
Mailing Address - Phone:330-841-4000
Mailing Address - Fax:
Practice Address - Street 1:3300 E SOUTH ST STE 308
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90805-4598
Practice Address - Country:US
Practice Address - Phone:562-630-3111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-17
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH58.006051207R00000X
CA20A15461207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20A15461OtherOSTEOPATHIC PHYSICIAN AND SURGEON