Provider Demographics
NPI:1669795431
Name:WILSHIRE MEDICAL CLINIC
Entity type:Organization
Organization Name:WILSHIRE MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ARTIS
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODWARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-387-8402
Mailing Address - Street 1:3540 WILSHIRE BLVD
Mailing Address - Street 2:SUITE: 1014
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-2307
Mailing Address - Country:US
Mailing Address - Phone:213-387-8024
Mailing Address - Fax:213-387-8916
Practice Address - Street 1:3540 WILSHIRE BLVD
Practice Address - Street 2:SUITE: 1014
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-2307
Practice Address - Country:US
Practice Address - Phone:213-387-8024
Practice Address - Fax:213-387-8916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-09
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA102066204C00000X
CAA40408207L00000X
CAA10037207X00000X
CAG36302207Y00000X
207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty