Provider Demographics
NPI:1508829680
Name:ROOT, WESLEY EATON (MD)
Entity type:Individual
Prefix:
First Name:WESLEY
Middle Name:EATON
Last Name:ROOT
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:PO BOX 3222
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-0293
Mailing Address - Country:US
Mailing Address - Phone:707-261-7823
Mailing Address - Fax:707-256-3508
Practice Address - Street 1:3800 JANES RD
Practice Address - Street 2:
Practice Address - City:ARCATA
Practice Address - State:CA
Practice Address - Zip Code:95521
Practice Address - Country:US
Practice Address - Phone:707-825-4972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-10
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA238512085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00429943OtherRAILROAD MEDICARE
DG3352OtherRAILROAD MEDICARE GROUP
CA00A238510Medicaid
00A238514Medicare PIN
DG3352OtherRAILROAD MEDICARE GROUP
CA00A238510Medicaid