Healthcare Provider Details

I. General information

NPI: 1083068936
Provider Name (Legal Business Name): WESLEY GHASEM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2016
Last Update Date: 07/06/2022
Certification Date: 07/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14860 ROSCOE BLVD STE 200
PANORAMA CITY CA
91402-4683
US

IV. Provider business mailing address

1200 N STATE ST CT-A7D
LOS ANGELES CA
90033
US

V. Phone/Fax

Practice location:
  • Phone: 310-553-5203
  • Fax: 310-652-0933
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberA153555
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberA153555
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: