Healthcare Provider Details

I. General information

NPI: 1447363692
Provider Name (Legal Business Name): WILSHIRE DISTRICT MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 10/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1314 WILSHIRE BLVD.
LOS ANGELES CA
90017-1705
US

IV. Provider business mailing address

13521 TELEGRAPH RD STE B
WHITTIER CA
90605-3462
US

V. Phone/Fax

Practice location:
  • Phone: 213-384-5132
  • Fax: 213-234-4542
Mailing address:
  • Phone: 562-946-7571
  • Fax: 213-234-4542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA69991
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA69991
License Number StateCA

VIII. Authorized Official

Name: DR. SIMON JIANG
Title or Position: CEO
Credential: M.D.
Phone: 213-384-5132