Provider Demographics
NPI:1801587860
Name:WETHERELL, DAVID (ABOC, NCLEC)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:WETHERELL
Suffix:
Gender:M
Credentials:ABOC, NCLEC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2203 SW COURT PL
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801-1896
Mailing Address - Country:US
Mailing Address - Phone:541-276-2905
Mailing Address - Fax:541-276-2918
Practice Address - Street 1:2203 SW COURT PL
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801-1896
Practice Address - Country:US
Practice Address - Phone:541-276-2905
Practice Address - Fax:541-276-2918
Is Sole Proprietor?:No
Enumeration Date:2023-05-18
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR216334156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician