Provider Demographics
NPI:1083022339
Name:DEPAULA, WEVERTON
Entity Type:Individual
Prefix:
First Name:WEVERTON
Middle Name:
Last Name:DEPAULA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 INDIAN RIVER RD
Mailing Address - Street 2:C-3
Mailing Address - City:ORANGE
Mailing Address - State:CT
Mailing Address - Zip Code:06477-3649
Mailing Address - Country:US
Mailing Address - Phone:203-553-9797
Mailing Address - Fax:
Practice Address - Street 1:240 INDIAN RIVER RD
Practice Address - Street 2:C-3
Practice Address - City:ORANGE
Practice Address - State:CT
Practice Address - Zip Code:06477-3649
Practice Address - Country:US
Practice Address - Phone:203-553-9797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-31
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001647156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician