Provider Demographics
NPI:1679679336
Name:WESP, CLYDE JR (MD)
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:
Last Name:WESP
Suffix:JR
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 1:23321 EL TORO RD
Mailing Address - Street 2:SUITES F&G
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-4825
Mailing Address - Country:US
Mailing Address - Phone:949-770-0513
Mailing Address - Fax:
Practice Address - Street 1:800 CORPORATE DR
Practice Address - Street 2:SUITE 280
Practice Address - City:LADERA RANCH
Practice Address - State:CA
Practice Address - Zip Code:92694-1152
Practice Address - Country:US
Practice Address - Phone:949-388-1798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG45946208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics