Provider Demographics
NPI:1861796989
Name:WHEELER, JEDEDIAH LARSEN (DO)
Entity type:Individual
Prefix:
First Name:JEDEDIAH
Middle Name:LARSEN
Last Name:WHEELER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:ATTN: CREDENTIALING/PAYER ENROLLMENT
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1820 41ST AVE STE D
Practice Address - Street 2:
Practice Address - City:CAPITOLA
Practice Address - State:CA
Practice Address - Zip Code:95010-2516
Practice Address - Country:US
Practice Address - Phone:831-476-3000
Practice Address - Fax:831-476-9009
Is Sole Proprietor?:No
Enumeration Date:2011-01-04
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A11998208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics