Healthcare Provider Details

I. General information

NPI: 1114063294
Provider Name (Legal Business Name): GLENN P. WEDEEN MD A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15248 11TH ST
VICTORVILLE CA
92395-3704
US

IV. Provider business mailing address

PO BOX 7630
LAGUNA NIGUEL CA
92607-7630
US

V. Phone/Fax

Practice location:
  • Phone: 760-245-8691
  • Fax:
Mailing address:
  • Phone: 949-643-3345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberG75574
License Number StateCA

VIII. Authorized Official

Name: DR. GLENN P WEDEEN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 626-357-8535