Provider Demographics
NPI:1609894484
Name:WESTON MEDICAL CLINIC INC
Entity Type:Organization
Organization Name:WESTON MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PHANOR
Authorized Official - Middle Name:
Authorized Official - Last Name:CALLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-385-9711
Mailing Address - Street 1:17120 ROYAL PALM BLVD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326-2310
Mailing Address - Country:US
Mailing Address - Phone:954-385-3711
Mailing Address - Fax:954-385-9366
Practice Address - Street 1:17120 ROYAL PALM BLVD
Practice Address - Street 2:SUITE 4
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33326-2310
Practice Address - Country:US
Practice Address - Phone:954-385-3711
Practice Address - Fax:954-385-9366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0073727207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL255505100Medicaid
FL255505100Medicaid
FLG09972Medicare UPIN