Provider Demographics
NPI:1770686552
Name:WETZEL, RANDALL CLYDE (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:CLYDE
Last Name:WETZEL
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 1:6430 W SUNSET BLVD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-7901
Mailing Address - Country:US
Mailing Address - Phone:323-361-2557
Mailing Address - Fax:323-644-8488
Practice Address - Street 1:4650 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6062
Practice Address - Country:US
Practice Address - Phone:323-361-2557
Practice Address - Fax:323-664-0728
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC50084207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C500840Medicaid
CA00C500840Medicaid
CAB67074Medicare UPIN