Basic Information
| Provider Information | |||||||||
| NPI: | 1316955792 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOGENS U WIESE MD INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1633 ERRINGER RD | ||||||||
| Address2: | 1ST FLOOR | ||||||||
| City: | SIMI VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930653583 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055788300 | ||||||||
| FaxNumber: | 8055788950 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 W JANSS RD | ||||||||
| Address2: | |||||||||
| City: | THOUSAND OAKS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913601847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104715852 | ||||||||
| FaxNumber: | 3104713958 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 11/16/2009 | ||||||||
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| AuthorizedOfficialLastName: | WIESE | ||||||||
| AuthorizedOfficialFirstName: | MOGENS | ||||||||
| AuthorizedOfficialMiddleName: | U. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3104715852 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | A37380 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | GR0052481 | 05 | CA | MEDICAID | GR0052480 | 05 | CA | MEDICAID |