Provider Demographics
NPI:1750315404
Name:WIEDER, JOSHUA MARTIN (MD)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:MARTIN
Last Name:WIEDER
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 1:12301 WILSHIRE BLVD
Mailing Address - Street 2:201
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1007
Mailing Address - Country:US
Mailing Address - Phone:310-207-8900
Mailing Address - Fax:
Practice Address - Street 1:12301 WILSHIRE BLVD
Practice Address - Street 2:201
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1007
Practice Address - Country:US
Practice Address - Phone:310-207-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2015-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG70745207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE38051Medicare UPIN
CAWG70745CMedicare ID - Type UnspecifiedPPIN #