Provider Demographics
NPI:1356599963
Name:WIGHTMAN, WAYNE DOUGLAS (MD)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:DOUGLAS
Last Name:WIGHTMAN
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 1:23456 HAWTHORNE BLVD
Mailing Address - Street 2:SUITE 160
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-4716
Mailing Address - Country:US
Mailing Address - Phone:310-375-2705
Mailing Address - Fax:310-375-2701
Practice Address - Street 1:23456 HAWTHORNE BLVD
Practice Address - Street 2:SUITE 160
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4716
Practice Address - Country:US
Practice Address - Phone:310-375-2705
Practice Address - Fax:310-375-2701
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-08
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA25658207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine