Provider Demographics
NPI:1851505432
Name:P. PERRY WICH, M.D., INC.
Entity type:Organization
Organization Name:P. PERRY WICH, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:P.
Authorized Official - Middle Name:PERRY
Authorized Official - Last Name:WICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-946-3826
Mailing Address - Street 1:630 N 13TH AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4975
Mailing Address - Country:US
Mailing Address - Phone:909-946-3826
Mailing Address - Fax:909-949-4457
Practice Address - Street 1:630 N 13TH AVE
Practice Address - Street 2:SUITE F
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4975
Practice Address - Country:US
Practice Address - Phone:909-946-3826
Practice Address - Fax:909-949-4457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA326602084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0002030Medicaid
CA00A326600Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
CAGR0002030Medicaid