Healthcare Provider Details

I. General information

NPI: 1124342266
Provider Name (Legal Business Name): WANDER STENIO SEGURA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2010
Last Update Date: 08/15/2025
Certification Date: 08/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

483 N AVIATION BLVD BLDG 210
EL SEGUNDO CA
90245-2808
US

IV. Provider business mailing address

483 N AVIATION BLVD BLDG 210
EL SEGUNDO CA
90245-2808
US

V. Phone/Fax

Practice location:
  • Phone: 310-653-6679
  • Fax:
Mailing address:
  • Phone: 310-653-6679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberC199543
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME135277
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: