Provider Demographics
NPI:1588957849
Name:WIEBE, JONATHAN PATRICK (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:PATRICK
Last Name:WIEBE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11303 W WASHINGTON BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-6003
Mailing Address - Country:US
Mailing Address - Phone:434-227-2628
Mailing Address - Fax:
Practice Address - Street 1:11303 W WASHINGTON BLVD STE 100
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-6003
Practice Address - Country:US
Practice Address - Phone:434-227-2628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-19
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA121310207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHN014ZMedicare PIN