Provider Demographics
NPI:1174672885
Name:WERTHEIMER, FIONA BAERVELDT (DO)
Entity Type:Individual
Prefix:
First Name:FIONA
Middle Name:BAERVELDT
Last Name:WERTHEIMER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 ZONAL AVE
Mailing Address - Street 2:IRD 820
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-1019
Mailing Address - Country:US
Mailing Address - Phone:323-226-3406
Mailing Address - Fax:323-226-3440
Practice Address - Street 1:2020 ZONAL AVE
Practice Address - Street 2:IRD 820
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-1019
Practice Address - Country:US
Practice Address - Phone:323-226-3406
Practice Address - Fax:323-226-3440
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS10427208000000X
CA20A10827208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0001049-00Medicaid
FLBG266ZMedicare PIN