Healthcare Provider Details

I. General information

NPI: 1669795431
Provider Name (Legal Business Name): WILSHIRE MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2010
Last Update Date: 03/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3540 WILSHIRE BLVD SUITE: 1014
LOS ANGELES CA
90010-2307
US

IV. Provider business mailing address

3540 WILSHIRE BLVD SUITE: 1014
LOS ANGELES CA
90010-2307
US

V. Phone/Fax

Practice location:
  • Phone: 213-387-8024
  • Fax: 213-387-8916
Mailing address:
  • Phone: 213-387-8024
  • Fax: 213-387-8916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberA102066
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA40408
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberA10037
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberG36302
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: ARTIS WOODWARD
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 213-387-8402