Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208D00000X | General Practice Physician | A69610 | CA |
NPI | 1043580921 |
---|---|
Provider Name | Dr. Jay Wohlgemuth |
First Address | San Juan Capistrano, CA 92675-2042 |
Second Address | San Juan Capistrano, CA 92675-2042 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/01/2012 |
Last Update Date | 09/01/2012 |