Provider Demographics
NPI:1811040413
Name:WEITKAMP, JAMES W (OD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:W
Last Name:WEITKAMP
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 S HALCYON RD
Mailing Address - Street 2:
Mailing Address - City:ARROYO GRANDE
Mailing Address - State:CA
Mailing Address - Zip Code:93420-3135
Mailing Address - Country:US
Mailing Address - Phone:805-489-8410
Mailing Address - Fax:805-233-6375
Practice Address - Street 1:260 S HALCYON RD
Practice Address - Street 2:
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420-3135
Practice Address - Country:US
Practice Address - Phone:805-489-8410
Practice Address - Fax:805-233-6375
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13063152W00000X
156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACU349AMedicare PIN