Provider Demographics
NPI:1902190820
Name:WESTON, ALICE S (MD)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:S
Last Name:WESTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4104 SE 82ND AVE
Mailing Address - Street 2:SUITE 250
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-2954
Mailing Address - Country:US
Mailing Address - Phone:503-215-9850
Mailing Address - Fax:
Practice Address - Street 1:4104 SE 82ND AVE
Practice Address - Street 2:SUITE 250
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-2954
Practice Address - Country:US
Practice Address - Phone:503-215-9850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-08
Last Update Date:2017-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD163182207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine