Provider Demographics
NPI:1487987905
Name:WILSHIRE MULTI-SPECIALTY CLINIC
Entity type:Organization
Organization Name:WILSHIRE MULTI-SPECIALTY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KUSUM
Authorized Official - Middle Name:
Authorized Official - Last Name:RUDRAPPA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-388-3712
Mailing Address - Street 1:3540 WILSHIRE BLVD
Mailing Address - Street 2:STE: 1028
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-2307
Mailing Address - Country:US
Mailing Address - Phone:213-388-3712
Mailing Address - Fax:213-388-0734
Practice Address - Street 1:3540 WILSHIRE BLVD
Practice Address - Street 2:STE: 1028
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-2307
Practice Address - Country:US
Practice Address - Phone:213-388-3712
Practice Address - Fax:213-388-0734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-16
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG87522152W00000X
207QS1201X
CAA37070207RS0010X, 208D00000X
CAA54260207RS0012X
CAG36302207Y00000X
CAPSY123312084P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No207QS1201XAllopathic & Osteopathic PhysiciansFamily MedicineSleep MedicineGroup - Multi-Specialty
No207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports MedicineGroup - Multi-Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA37070Medicare UPIN