Provider Demographics
NPI:1437452448
Name:JOSHUA M WIEDER MD INC
Entity type:Organization
Organization Name:JOSHUA M WIEDER MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:M
Authorized Official - Last Name:WIEDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-209-1440
Mailing Address - Street 1:12301 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1007
Mailing Address - Country:US
Mailing Address - Phone:310-207-8900
Mailing Address - Fax:310-207-8912
Practice Address - Street 1:12301 WILSHIRE BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1007
Practice Address - Country:US
Practice Address - Phone:310-207-8900
Practice Address - Fax:310-207-8912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-13
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG70745207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE38051Medicare UPIN