Provider Demographics
NPI:1700910049
Name:WEATHERLY, JOHN (RPT)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:WEATHERLY
Suffix:
Gender:M
Credentials:RPT
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 3914
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-3914
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:850 LINCOLN DR
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4922
Practice Address - Country:US
Practice Address - Phone:208-569-4266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1805225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP00016855Medicare ID - Type UnspecifiedRAILROAD MEDICARE CARRIER
ID1654693Medicare ID - Type UnspecifiedPERFORMING PROVIDER #
ID1375073Medicare ID - Type UnspecifiedGROUP PRICING IDENTIFIER