Provider Demographics
NPI:1871551564
Name:WETTSTEIN, WENDELL E (MD)
Entity type:Individual
Prefix:DR
First Name:WENDELL
Middle Name:E
Last Name:WETTSTEIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12370 HESPERIA RD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-7719
Mailing Address - Country:US
Mailing Address - Phone:760-245-4747
Mailing Address - Fax:
Practice Address - Street 1:12408 HESPERIA RD
Practice Address - Street 2:SUITE 2
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-7718
Practice Address - Country:US
Practice Address - Phone:760-553-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG31737208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA44851Medicare UPIN