Provider Demographics
NPI:1972646867
Name:WEISENBACH, JAMES H (OD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:H
Last Name:WEISENBACH
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 1:4803 138TH ST NE
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98271-7827
Mailing Address - Country:US
Mailing Address - Phone:360-659-6160
Mailing Address - Fax:
Practice Address - Street 1:8924 34TH AVE NE
Practice Address - Street 2:
Practice Address - City:TULALIP
Practice Address - State:WA
Practice Address - Zip Code:98271-8076
Practice Address - Country:US
Practice Address - Phone:369-657-5273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA950TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2005593Medicaid
WAWE6015Medicare UPIN