Healthcare Provider Details

I. General information

NPI: 1053458950
Provider Name (Legal Business Name): DWIGHT E HISCOX M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 03/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1509 WILSON TER
GLENDALE CA
91206-4007
US

IV. Provider business mailing address

PO BOX 5486
ORANGE CA
92863-5486
US

V. Phone/Fax

Practice location:
  • Phone: 818-550-0900
  • Fax: 505-293-1524
Mailing address:
  • Phone: 818-550-0900
  • Fax: 505-293-1524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberG34805
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: