Provider Demographics
NPI:1164692968
Name:WILSHIRE MEDICAL P.C.
Entity Type:Organization
Organization Name:WILSHIRE MEDICAL P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:SOPER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-329-7022
Mailing Address - Street 1:6820 PARKDALE PL
Mailing Address - Street 2:STE 212
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-6601
Mailing Address - Country:US
Mailing Address - Phone:317-329-7022
Mailing Address - Fax:317-329-7031
Practice Address - Street 1:6820 PARKDALE PL
Practice Address - Street 2:STE 212
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-6601
Practice Address - Country:US
Practice Address - Phone:317-329-7022
Practice Address - Fax:317-329-7031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-07
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100078880AMedicaid