Provider Demographics
NPI:1932484987
Name:WETTERHOLT, DAVID G (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:G
Last Name:WETTERHOLT
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 1:14054 ALTA VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:SARATOGA
Mailing Address - State:CA
Mailing Address - Zip Code:95070-5422
Mailing Address - Country:US
Mailing Address - Phone:408-446-4774
Mailing Address - Fax:408-446-9422
Practice Address - Street 1:12224 SARATOGA SUNNYVALE RD
Practice Address - Street 2:
Practice Address - City:SARATOGA
Practice Address - State:CA
Practice Address - Zip Code:95070-3047
Practice Address - Country:US
Practice Address - Phone:408-446-4774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-20
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG24402208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA42248Medicare UPIN