Basic Information
| Provider Information | |||||||||
| NPI: | 1649515750 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WILSHIRE ONCOLOGY MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1502 ARROW HWY | ||||||||
| Address2: | |||||||||
| City: | LA VERNE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917505318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095934333 | ||||||||
| FaxNumber: | 9095935588 | ||||||||
| Practice Location | |||||||||
| Address1: | 1280 CORONA POINTE CT | ||||||||
| Address2: | SUITE 112 | ||||||||
| City: | CORONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928791770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9518982828 | ||||||||
| FaxNumber: | 9518982811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2012 | ||||||||
| LastUpdateDate: | 11/29/2012 | ||||||||
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| AuthorizedOfficialLastName: | BOSSERMAN | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9095934333 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.