Healthcare Provider Details

I. General information

NPI: 1356599963
Provider Name (Legal Business Name): WAYNE DOUGLAS WIGHTMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2008
Last Update Date: 09/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23456 HAWTHORNE BLVD SUITE 160
TORRANCE CA
90505-4716
US

IV. Provider business mailing address

23456 HAWTHORNE BLVD SUITE 160
TORRANCE CA
90505-4716
US

V. Phone/Fax

Practice location:
  • Phone: 310-375-2705
  • Fax: 310-375-2701
Mailing address:
  • Phone: 310-375-2705
  • Fax: 310-375-2701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA25658
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: