Provider Demographics
NPI:1841781812
Name:LAGRANDEUR, WESTON JOHN (MD)
Entity type:Individual
Prefix:
First Name:WESTON
Middle Name:JOHN
Last Name:LAGRANDEUR
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 1:455 OCONNOR DR STE 210
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-1632
Mailing Address - Country:US
Mailing Address - Phone:408-995-5453
Mailing Address - Fax:
Practice Address - Street 1:455 OCONNOR DR STE 210
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1632
Practice Address - Country:US
Practice Address - Phone:408-995-5453
Practice Address - Fax:206-812-6176
Is Sole Proprietor?:No
Enumeration Date:2018-05-24
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA194474207Q00000X
WAMD61142151207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2194638Medicaid
CA1841781812Medicaid