=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689931818
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEVEN ANDREW WISEL MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2012
-----------------------------------------------------
Last Update Date | 02/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8900 BEVERLY BLVD FL 3
-----------------------------------------------------
City | WEST HOLLYWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90048-2438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-423-2641
-----------------------------------------------------
Fax | 310-423-0234
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4140 W 190TH ST
-----------------------------------------------------
City | TORRANCE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90504-5513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 128350
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 204F00000X
-----------------------------------------------------
Taxonomy Name | Transplant Surgery Physician
-----------------------------------------------------
License Number | A128350
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------