Provider Demographics
NPI:1245506195
Name:WEIVODA, STARCHILD (DO)
Entity type:Individual
Prefix:
First Name:STARCHILD
Middle Name:
Last Name:WEIVODA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 S BLOSSER RD
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93458-7310
Mailing Address - Country:US
Mailing Address - Phone:805-361-8030
Mailing Address - Fax:805-361-8097
Practice Address - Street 1:4711 HIGHWAY 166
Practice Address - Street 2:
Practice Address - City:NEW CUYAMA
Practice Address - State:CA
Practice Address - Zip Code:93254
Practice Address - Country:US
Practice Address - Phone:661-766-2149
Practice Address - Fax:661-766-2350
Is Sole Proprietor?:No
Enumeration Date:2012-03-26
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02004645A207Q00000X
CA18475207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201320520Medicaid
AK1647495Medicaid