Provider Demographics
NPI:1104010248
Name:WILSHIRE DISTRICT MEDICAL GROUP
Entity Type:Organization
Organization Name:WILSHIRE DISTRICT MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SIMON
Authorized Official - Middle Name:
Authorized Official - Last Name:JIANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-458-3132
Mailing Address - Street 1:13521 TELEGRAPH RD STE B
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90605-3462
Mailing Address - Country:US
Mailing Address - Phone:562-946-7571
Mailing Address - Fax:
Practice Address - Street 1:925 S ATLANTIC BLVD STE 106
Practice Address - Street 2:
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754
Practice Address - Country:US
Practice Address - Phone:213-458-3132
Practice Address - Fax:213-234-4542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-31
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69991261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A699911Medicaid
CAW16118Medicare PIN