Provider Demographics
NPI:1275577504
Name:WEDEEN, GLENN P (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:P
Last Name:WEDEEN
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:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93062-0190
Mailing Address - Country:US
Mailing Address - Phone:805-522-5940
Mailing Address - Fax:805-522-6401
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:760-843-6092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG755742085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G755740Medicaid
CA00G755740Medicaid