Provider Demographics
NPI:1134178437
Name:WIGHT, STEPHEN E (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:E
Last Name:WIGHT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:711 W COLLEGE ST
Mailing Address - Street 2:628
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90012-1163
Mailing Address - Country:US
Mailing Address - Phone:213-830-8920
Mailing Address - Fax:213-830-8925
Practice Address - Street 1:437 E WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-3720
Practice Address - Country:US
Practice Address - Phone:213-746-6423
Practice Address - Fax:213-746-6128
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG85650207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G856500Medicaid
CAWG85650Medicare ID - Type Unspecified
C63354Medicare UPIN