Provider Demographics
NPI:1104853944
Name:WESLEY, DAVID T (OD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:T
Last Name:WESLEY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 OAKHILL RD
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:AL
Mailing Address - Zip Code:35504-7415
Mailing Address - Country:US
Mailing Address - Phone:205-221-7779
Mailing Address - Fax:205-221-8742
Practice Address - Street 1:302 OAKHILL RD
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:AL
Practice Address - Zip Code:35504-7465
Practice Address - Country:US
Practice Address - Phone:205-221-7779
Practice Address - Fax:205-221-8742
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS762TA265152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009951625Medicaid
AL009951625Medicaid
AL000058584Medicare ID - Type Unspecified