Provider Demographics
NPI:1316955792
Name:MOGENS U WIESE MD INC
Entity type:Organization
Organization Name:MOGENS U WIESE MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MOGENS
Authorized Official - Middle Name:U
Authorized Official - Last Name:WIESE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-471-5852
Mailing Address - Street 1:1633 ERRINGER RD
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-3583
Mailing Address - Country:US
Mailing Address - Phone:805-578-8300
Mailing Address - Fax:805-578-8950
Practice Address - Street 1:215 W JANSS RD
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-1847
Practice Address - Country:US
Practice Address - Phone:310-471-5852
Practice Address - Fax:310-471-3958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA37380207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0052481Medicaid
CAGR0052480Medicaid
CAGR0052480Medicaid