Provider Demographics
NPI:1467640011
Name:WILSHIRE ONCOLOGY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:WILSHIRE ONCOLOGY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:DIANA
Authorized Official - Last Name:BOSSERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-593-4333
Mailing Address - Street 1:1502 ARROW HWY
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-5318
Mailing Address - Country:US
Mailing Address - Phone:909-593-4333
Mailing Address - Fax:909-593-5588
Practice Address - Street 1:1250 S SUNSET AVE
Practice Address - Street 2:303
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-3961
Practice Address - Country:US
Practice Address - Phone:626-856-5858
Practice Address - Fax:909-593-5588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ83087ZMedicaid
CAZZZ83087ZMedicaid