Provider Demographics
NPI:1609867738
Name:WEISS, WENDY EVE (DO)
Entity Type:Individual
Prefix:DR
First Name:WENDY
Middle Name:EVE
Last Name:WEISS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:WENDY
Other - Middle Name:EVE
Other - Last Name:DASILVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:575 PRICE ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-2553
Mailing Address - Country:US
Mailing Address - Phone:805-773-0707
Mailing Address - Fax:805-773-2051
Practice Address - Street 1:575 PRICE ST
Practice Address - Street 2:SUITE 101
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-2553
Practice Address - Country:US
Practice Address - Phone:805-773-0707
Practice Address - Fax:805-773-2051
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-28
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6436207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX64360Medicaid
CA020A64360OtherBLUE SHIELD PIN
CAW20A6436GMedicare PIN
CAF76531Medicare UPIN
CAPOOO79370Medicare PIN