Basic Information
| Provider Information | |||||||||
| NPI: | 1649352675 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOHLERT | ||||||||
| FirstName: | LIBIA | ||||||||
| MiddleName: | ELENA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1770 N ORANGE GROVE AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917673027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094699494 | ||||||||
| FaxNumber: | 9094692120 | ||||||||
| Practice Location | |||||||||
| Address1: | 1770 N ORANGE GROVE AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917673027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094699494 | ||||||||
| FaxNumber: | 9094692120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 07/14/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A101093 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | AY732Z | 01 | CA | MEDICARE SO. CALIFORNIA | OTHER | FW0465888 | 01 | DEA | OTHER | AY732Y | 01 | CA | MEDICARE NORTHERN CALIFORNIA | OTHER | 1649352675 | 05 | CA | MEDICAID |