Provider Demographics
NPI:1043317217
Name:WICH, PEIRUCH PERRY
Entity Type:Individual
Prefix:MR
First Name:PEIRUCH
Middle Name:PERRY
Last Name:WICH
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:PEIRUCH
Other - Middle Name:
Other - Last Name:WICHIENKUER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:630 N 13TH AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4975
Mailing Address - Country:US
Mailing Address - Phone:909-946-3826
Mailing Address - Fax:909-949-4457
Practice Address - Street 1:630 N 13TH AVE
Practice Address - Street 2:SUITE F
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4975
Practice Address - Country:US
Practice Address - Phone:909-946-3826
Practice Address - Fax:909-949-4457
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA326602084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8208912Medicaid
D34034Medicare UPIN
CA8208912Medicaid