Provider Demographics
NPI:1649684093
Name:WESOLOW, JACQUELINE
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:
Last Name:WESOLOW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7505 ROTTINGHAM RD
Mailing Address - Street 2:
Mailing Address - City:PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34668-2648
Mailing Address - Country:US
Mailing Address - Phone:727-495-5190
Mailing Address - Fax:
Practice Address - Street 1:7505 ROTTINGHAM RD
Practice Address - Street 2:
Practice Address - City:PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34668-2648
Practice Address - Country:US
Practice Address - Phone:727-495-5190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-13
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS12792207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine