Basic Information
| Provider Information | |||||||||
| NPI: | 1871025551 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIVINGSTON | ||||||||
| FirstName: | WESLEY | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12223 HIGHLAND AVE STE 106-526 | ||||||||
| Address2: | |||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917392574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146763880 | ||||||||
| FaxNumber: | 9096148582 | ||||||||
| Practice Location | |||||||||
| Address1: | 4445 MAGNOLIA AVE | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925014135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146763880 | ||||||||
| FaxNumber: | 9096148582 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2017 | ||||||||
| LastUpdateDate: | 11/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 19084 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | 19084 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 19084 | CA | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 390200000 | 05 | NY | MEDICAID |