Provider Demographics
NPI:1043363807
Name:ROBERT J. WIELENGA, MD, A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:ROBERT J. WIELENGA, MD, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:WIELENGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-923-9100
Mailing Address - Street 1:10835 NEW ST
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90241-3714
Mailing Address - Country:US
Mailing Address - Phone:562-923-9100
Mailing Address - Fax:562-923-9103
Practice Address - Street 1:10835 NEW ST
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-3714
Practice Address - Country:US
Practice Address - Phone:562-923-9100
Practice Address - Fax:562-923-9103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG81044207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG81044Medicare ID - Type Unspecified
CAG45597Medicare UPIN