Provider Demographics
NPI:1952469850
Name:WIELENGA, ROBERT JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JAMES
Last Name:WIELENGA
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 1:10835 NEW ST
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90241-3714
Mailing Address - Country:US
Mailing Address - Phone:562-923-9100
Mailing Address - Fax:562-923-9103
Practice Address - Street 1:10835 NEW ST
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-3714
Practice Address - Country:US
Practice Address - Phone:562-923-9100
Practice Address - Fax:562-923-9103
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG81044207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG45597Medicare UPIN
CAG81044Medicare ID - Type UnspecifiedMEDICARE