Healthcare Provider Details

I. General information

NPI: 1063674190
Provider Name (Legal Business Name): PAUL JOHN WISNIEWSKI D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2008
Last Update Date: 10/31/2025
Certification Date: 10/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18523 CORWIN RD STE A
APPLE VALLEY CA
92307-2300
US

IV. Provider business mailing address

18523 CORWIN RD STE A
APPLE VALLEY CA
92307-2300
US

V. Phone/Fax

Practice location:
  • Phone: 909-353-5285
  • Fax:
Mailing address:
  • Phone: 909-712-2764
  • Fax: 909-752-8719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberCA209062
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberOS 12023
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number20A9062
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberDO034774
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: