Provider Demographics
NPI:1043493026
Name:CHARLES E WEIDMANN MD A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:CHARLES E WEIDMANN MD A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D., OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:ERNEST
Authorized Official - Last Name:WEIDMANN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-781-0232
Mailing Address - Street 1:15243 VANOWEN ST
Mailing Address - Street 2:STE 306
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-3605
Mailing Address - Country:US
Mailing Address - Phone:818-781-0232
Mailing Address - Fax:818-781-4132
Practice Address - Street 1:15243 VANOWEN ST
Practice Address - Street 2:STE 306
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-3649
Practice Address - Country:US
Practice Address - Phone:818-781-0232
Practice Address - Fax:818-781-4132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-12
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG48620207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G486200Medicaid
CA00G486200Medicaid