Healthcare Provider Details

I. General information

NPI: 1578667069
Provider Name (Legal Business Name): JOHN WIX THOMAS III MD ENT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1703 TERMINO AVE #210
LONG BEACH CA
90804
US

IV. Provider business mailing address

1703 TERMINO AVE #210
LONG BEACH CA
90804
US

V. Phone/Fax

Practice location:
  • Phone: 562-498-6653
  • Fax: 562-498-7794
Mailing address:
  • Phone: 562-498-6653
  • Fax: 562-498-7794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberG13538
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: