Basic Information
| Provider Information | |||||||||
| NPI: | 1316144975 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VIELMAN | ||||||||
| FirstName: | LUDIM | ||||||||
| MiddleName: | ESTUARDO | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 459 S. CENTRAL VALLEY HWY | ||||||||
| Address2: | |||||||||
| City: | SHAFTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6614591913 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 21138 PASO ROBLES HWY | ||||||||
| Address2: | |||||||||
| City: | LOST HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6619792667 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2007 | ||||||||
| LastUpdateDate: | 08/24/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA19232 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PA19232 | 01 | CA | CALIFORNIA MEDICAL BOARD | OTHER |