Healthcare Provider Details

I. General information

NPI: 1487987905
Provider Name (Legal Business Name): WILSHIRE MULTI-SPECIALTY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2009
Last Update Date: 09/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3540 WILSHIRE BLVD STE: 1028
LOS ANGELES CA
90010-2307
US

IV. Provider business mailing address

3540 WILSHIRE BLVD STE: 1028
LOS ANGELES CA
90010-2307
US

V. Phone/Fax

Practice location:
  • Phone: 213-388-3712
  • Fax: 213-388-0734
Mailing address:
  • Phone: 213-388-3712
  • Fax: 213-388-0734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberG87522
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207QS1201X
TaxonomySleep Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License NumberA37070
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License NumberA54260
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberG36302
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code2084P2900X
TaxonomyPain Medicine (Psychiatry & Neurology) Physician
License NumberPSY12331
License Number StateCA
# 7
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA37070
License Number StateCA

VIII. Authorized Official

Name: KUSUM RUDRAPPA
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 213-388-3712