Provider Demographics
NPI:1093914921
Name:WESLEY A KING MD A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:WESLEY A KING MD A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-385-1918
Mailing Address - Street 1:122 SHELDON ST
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-3915
Mailing Address - Country:US
Mailing Address - Phone:310-322-4278
Mailing Address - Fax:310-570-2231
Practice Address - Street 1:8436 W 3RD ST STE 800
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-4100
Practice Address - Country:US
Practice Address - Phone:310-385-1918
Practice Address - Fax:323-433-7106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-11
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA42379207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW18039Medicare PIN