Provider Demographics
NPI:1194772202
Name:WETTSTEIN SAWAN MEDICAL GROUP INC
Entity type:Organization
Organization Name:WETTSTEIN SAWAN MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:
Authorized Official - Last Name:NEAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-241-7773
Mailing Address - Street 1:12370 HESPERIA RD
Mailing Address - Street 2:SUITE 15
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-7719
Mailing Address - Country:US
Mailing Address - Phone:760-241-7773
Mailing Address - Fax:760-241-7793
Practice Address - Street 1:12370 HESPERIA RD
Practice Address - Street 2:SUITE 15
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-7719
Practice Address - Country:US
Practice Address - Phone:760-241-7773
Practice Address - Fax:760-241-7793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ22721ZMedicare ID - Type Unspecified