=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316955792
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOGENS U WIESE MD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2006
-----------------------------------------------------
Last Update Date | 11/16/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 215 W JANSS RD
-----------------------------------------------------
City | THOUSAND OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91360-1847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-471-5852
-----------------------------------------------------
Fax | 310-471-3958
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1633 ERRINGER RD 1ST FLOOR
-----------------------------------------------------
City | SIMI VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93065-3583
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-578-8300
-----------------------------------------------------
Fax | 805-578-8950
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. MOGENS U. WIESE
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 310-471-5852
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | A37380
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------