Provider Demographics
NPI:1871025551
Name:LIVINGSTON, WESLEY (DO)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:
Last Name:LIVINGSTON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12223 HIGHLAND AVE STE 106-526
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-2574
Mailing Address - Country:US
Mailing Address - Phone:714-676-3880
Mailing Address - Fax:909-614-8582
Practice Address - Street 1:4445 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-4135
Practice Address - Country:US
Practice Address - Phone:714-676-3880
Practice Address - Fax:909-614-8582
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-31
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19084207Q00000X, 207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY390200000Medicaid