Provider Demographics
NPI:1639267263
Name:WEATHERWAX, SCOTT W (MD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:W
Last Name:WEATHERWAX
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 2757
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92859-0757
Mailing Address - Country:US
Mailing Address - Phone:714-973-2650
Mailing Address - Fax:714-973-2655
Practice Address - Street 1:18952 MACARTHUR BLVD
Practice Address - Street 2:# 103
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92612-1432
Practice Address - Country:US
Practice Address - Phone:949-833-1432
Practice Address - Fax:949-705-5455
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG58975207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE02868Medicare UPIN