Provider Demographics
NPI:1326119165
Name:WILLIAM J WICKWIRE M D INC A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:WILLIAM J WICKWIRE M D INC A PROFESSIONAL CORPORATION
Other - Org Name:BEACH CITIES DEMATOLOGY MED CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NEAL
Authorized Official - Middle Name:M
Authorized Official - Last Name:AMMAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-798-1515
Mailing Address - Street 1:520 N PROSPECT AVE
Mailing Address - Street 2:STE 302
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-3041
Mailing Address - Country:US
Mailing Address - Phone:310-798-1515
Mailing Address - Fax:310-798-3131
Practice Address - Street 1:520 N PROSPECT AVE
Practice Address - Street 2:STE 302
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-3041
Practice Address - Country:US
Practice Address - Phone:310-798-1515
Practice Address - Fax:310-798-3131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG650830207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G650830OtherMEDICARE NORTHERN CA ID
CA00G650830Medicaid
CAZZZ06937ZMedicare PIN
CA00G650831Medicare PIN
CA00G650830OtherMEDICARE NORTHERN CA ID
CA00G650830Medicaid
CAW14911Medicare PIN
CAWG650830EMedicare PIN
CA070017594Medicare PIN
CAW14911AMedicare PIN