Provider Demographics
NPI:1376554162
Name:WENGER, MILDRED S (MD)
Entity Type:Individual
Prefix:DR
First Name:MILDRED
Middle Name:S
Last Name:WENGER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1031 W 34TH ST
Mailing Address - Street 2:USC ENGEMANN STUDENT HEALTH CENTER
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90089-3261
Mailing Address - Country:US
Mailing Address - Phone:323-461-9355
Mailing Address - Fax:323-461-7257
Practice Address - Street 1:1462 VINE ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90028-8146
Practice Address - Country:US
Practice Address - Phone:323-461-9355
Practice Address - Fax:323-461-7257
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48053207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF26628Medicare UPIN