Provider Demographics
NPI:1043238835
Name:WYMORE, DWIGHT ALAN (MD)
Entity Type:Individual
Prefix:
First Name:DWIGHT
Middle Name:ALAN
Last Name:WYMORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60790
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91116-6790
Mailing Address - Country:US
Mailing Address - Phone:626-795-6596
Mailing Address - Fax:626-795-8247
Practice Address - Street 1:4101 TORRANCE BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-4607
Practice Address - Country:US
Practice Address - Phone:310-540-7676
Practice Address - Fax:310-540-1485
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG51222207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G512220OtherBLUE SHIELD
CA00G512220Medicaid
CA00G512220OtherBLUE SHIELD
A89930Medicare UPIN
CA00G512220Medicaid