Healthcare Provider Details

I. General information

NPI: 1083662340
Provider Name (Legal Business Name): BEATA ANNA WICHERSKI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 04/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 FLOWER ST STE A
GLENDALE CA
91201-3000
US

IV. Provider business mailing address

1500 W WEST COVINA PKWY STE 201
WEST COVINA CA
91790-2703
US

V. Phone/Fax

Practice location:
  • Phone: 818-637-2000
  • Fax: 818-242-8761
Mailing address:
  • Phone: 626-263-7020
  • Fax: 626-960-9177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA53981
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: