Healthcare Provider Details

I. General information

NPI: 1114330370
Provider Name (Legal Business Name): MATTHEW DIARMUID WIEPKING MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2014
Last Update Date: 11/27/2023
Certification Date: 09/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 SAN PABLO ST FL 7
LOS ANGELES CA
90033-5313
US

IV. Provider business mailing address

PO BOX 31309
LOS ANGELES CA
90031-0309
US

V. Phone/Fax

Practice location:
  • Phone: 323-442-6254
  • Fax:
Mailing address:
  • Phone: 323-442-6254
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number35.129239
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberA155210
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: