1992194310 NPI number — ONE WEST MEDICAL GROUP, A PROFESSIONAL CORPORATION

Table of content: DR. DUSTY LEE MCIVER O.D. (NPI 1902994874)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992194310 NPI number — ONE WEST MEDICAL GROUP, A PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ONE WEST MEDICAL GROUP, A PROFESSIONAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1992194310
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/19/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 894874
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90189-4874
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-553-5203
Provider Business Mailing Address Fax Number:
310-652-0933

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8920 WILSHIRE BLVD STE 310
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEVERLY HILLS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90211-2003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-553-5203
Provider Business Practice Location Address Fax Number:
310-652-0933
Provider Enumeration Date:
01/22/2015

Additional Information

Authorized Official

Authorized Official Last Name:
WOOL-SMITH
Authorized Official First Name:
ASHLEY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
310-553-5203

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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