Provider Demographics
NPI:1245271303
Name:WETTSTEIN, MICHAEL EUGENE (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:EUGENE
Last Name:WETTSTEIN
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 1:11406 LOMA LINDA DR STE 516
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3711
Mailing Address - Country:US
Mailing Address - Phone:909-558-6204
Mailing Address - Fax:
Practice Address - Street 1:11406 LOMA LINDA DR STE 516
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3711
Practice Address - Country:US
Practice Address - Phone:909-558-6204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67921207LP2900X
ORMD22935207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP00415474OtherRAILROAD MEDICARE
WAB8867549Medicare PIN
WAH45343Medicare PIN