Provider Demographics
NPI:1114063294
Name:GLENN P. WEDEEN MD A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:GLENN P. WEDEEN MD A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:P
Authorized Official - Last Name:WEDEEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-357-8535
Mailing Address - Street 1:PO BOX 7630
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92607-7630
Mailing Address - Country:US
Mailing Address - Phone:949-643-3345
Mailing Address - Fax:
Practice Address - Street 1:15248 11TH ST
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-3704
Practice Address - Country:US
Practice Address - Phone:760-245-8691
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG755742085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG75574OtherSTATE LICENSE
CAG75574OtherSTATE LICENSE