Provider Demographics
NPI:1356423826
Name:WESTON, DOUGLAS (DO)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:
Last Name:WESTON
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 1:2601 AVENUE R
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-2501
Mailing Address - Country:US
Mailing Address - Phone:718-942-5353
Mailing Address - Fax:
Practice Address - Street 1:334 VAN SICKLEN ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-3802
Practice Address - Country:US
Practice Address - Phone:718-946-5380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY208709204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01818148Medicaid
NY01818148Medicaid
NY922912Medicare ID - Type Unspecified