Provider Demographics
NPI:1447363692
Name:WILSHIRE DISTRICT MEDICAL GROUP
Entity type:Organization
Organization Name:WILSHIRE DISTRICT MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SIMON
Authorized Official - Middle Name:
Authorized Official - Last Name:JIANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-384-5132
Mailing Address - Street 1:13521 TELEGRAPH RD STE B
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90605-3462
Mailing Address - Country:US
Mailing Address - Phone:562-946-7571
Mailing Address - Fax:213-234-4542
Practice Address - Street 1:1314 WILSHIRE BLVD.
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1705
Practice Address - Country:US
Practice Address - Phone:213-384-5132
Practice Address - Fax:213-234-4542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69991208000000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A699910Medicaid
CA4651510001Medicare NSC
W16118Medicare ID - Type Unspecified