Healthcare Provider Details

I. General information

NPI: 1679679336
Provider Name (Legal Business Name): CLYDE WESP JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 CORPORATE DR SUITE 280
LADERA RANCH CA
92694-1152
US

IV. Provider business mailing address

23321 EL TORO RD SUITES F&G
LAKE FOREST CA
92630-4825
US

V. Phone/Fax

Practice location:
  • Phone: 949-388-1798
  • Fax:
Mailing address:
  • Phone: 949-770-0513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG45946
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: