Provider Demographics
NPI:1558672998
Name:WEATHERLY, DAVID LOUIS (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:LOUIS
Last Name:WEATHERLY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:20952 E 12 MILE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-3203
Mailing Address - Country:US
Mailing Address - Phone:586-771-4820
Mailing Address - Fax:
Practice Address - Street 1:25 MICHIGAN ST NE STE 3300
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2558
Practice Address - Country:US
Practice Address - Phone:616-459-4171
Practice Address - Fax:616-459-0044
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2024-01-30
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Provider Licenses
StateLicense IDTaxonomies
MI4301096915208600000X, 2088P0231X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric Urology