Provider Demographics
NPI:1235182924
Name:NOTTAGE, WESLEY MERRILL (MD)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:MERRILL
Last Name:NOTTAGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 ODYSSEY
Mailing Address - Street 2:STE 205
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-3186
Mailing Address - Country:US
Mailing Address - Phone:949-586-3200
Mailing Address - Fax:949-900-2136
Practice Address - Street 1:23961 CALLE DE LA MAGDALENA
Practice Address - Street 2:SUITE 229
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3616
Practice Address - Country:US
Practice Address - Phone:949-581-7001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG29856207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ38138ZOtherBLUE SHIELD #
CA3962518OtherBLUE CROSS #
CAA44194Medicare UPIN
CAZZZ38138ZOtherBLUE SHIELD #