Provider Demographics
NPI:1710924378
Name:WEBER, KYLE C (MD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:C
Last Name:WEBER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:283 MADONNA RD STE B
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-5432
Mailing Address - Country:US
Mailing Address - Phone:805-549-8880
Mailing Address - Fax:805-783-2009
Practice Address - Street 1:283 MADONNA RD STE B
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-5432
Practice Address - Country:US
Practice Address - Phone:805-549-8880
Practice Address - Fax:805-783-2009
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT7581207Q00000X
CAG164375207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT93116OtherBLUE CROSS
MT152230Medicaid
F28135Medicare UPIN
MT85256Medicare ID - Type Unspecified