Provider Demographics
NPI:1083662340
Name:WICHERSKI, BEATA ANNA (MD)
Entity Type:Individual
Prefix:DR
First Name:BEATA
Middle Name:ANNA
Last Name:WICHERSKI
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:1500 W WEST COVINA PKWY
Mailing Address - Street 2:STE 201
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-2703
Mailing Address - Country:US
Mailing Address - Phone:626-263-7020
Mailing Address - Fax:626-960-9177
Practice Address - Street 1:777 FLOWER ST STE A
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91201-3000
Practice Address - Country:US
Practice Address - Phone:818-637-2000
Practice Address - Fax:818-242-8761
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2011-04-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA53981208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A539810Medicaid
CAG40419Medicare UPIN
CADA317ZMedicare PIN