Provider Demographics
NPI:1205866167
Name:DE WEESE, DAVID GEORGE (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:GEORGE
Last Name:DE WEESE
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2306 DEAN ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-3209
Mailing Address - Country:US
Mailing Address - Phone:707-443-8354
Mailing Address - Fax:707-443-8628
Practice Address - Street 1:2306 DEAN ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-3209
Practice Address - Country:US
Practice Address - Phone:707-443-8354
Practice Address - Fax:707-443-8628
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 12012174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT120120Medicare ID - Type Unspecified