Healthcare Provider Details

I. General information

NPI: 1104100197
Provider Name (Legal Business Name): ELENITA LUCERO WHEELER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2011
Last Update Date: 04/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20800 SHERMAN WAY
WINNETKA CA
91306-2707
US

IV. Provider business mailing address

20840 COMMUNITY ST UNIT 1
WINNETKA CA
91306-1500
US

V. Phone/Fax

Practice location:
  • Phone: 818-883-2273
  • Fax:
Mailing address:
  • Phone: 818-773-2687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA60725
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: