Basic Information
| Provider Information | |||||||||
| NPI: | 1578743720 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DWIGHT HISCOX, M.D., INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 951 | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912090951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8185500900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1509 WILSON TER | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912064007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8185500900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2007 | ||||||||
| LastUpdateDate: | 11/05/2007 | ||||||||
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| AuthorizedOfficialLastName: | HISCOX | ||||||||
| AuthorizedOfficialFirstName: | DWIGHT | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8185500900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00G348050 | 01 | CA | BLUESHIELD | OTHER |