Provider Demographics
NPI:1902128028
Name:TOM, WYNNSON W (MD)
Entity Type:Individual
Prefix:DR
First Name:WYNNSON
Middle Name:W
Last Name:TOM
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 1:400 N. TUSTIN AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3850
Mailing Address - Country:US
Mailing Address - Phone:714-560-1580
Mailing Address - Fax:770-701-6662
Practice Address - Street 1:2601 E CHAPMAN AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92869-3206
Practice Address - Country:US
Practice Address - Phone:714-633-0011
Practice Address - Fax:714-633-2238
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA101740207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADR123YMedicare PIN
CADR123AMedicare PIN