Provider Demographics
NPI:1982769295
Name:WETMORE, RICHARD DONALD (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:DONALD
Last Name:WETMORE
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 1:4203 BELFORT ROAD
Mailing Address - Street 2:SUITE 315
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-1418
Mailing Address - Country:US
Mailing Address - Phone:904-564-4369
Mailing Address - Fax:904-564-4376
Practice Address - Street 1:4203 BELFORT ROAD
Practice Address - Street 2:SUITE 315
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-1418
Practice Address - Country:US
Practice Address - Phone:904-564-4369
Practice Address - Fax:904-564-4376
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0059816207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME0059816OtherLICENSE NUMBER
FL101385OtherAVMED
FL12396OtherBLUE CROSS BLUE SHIELD
FL4198569OtherAETNA
FL12396OtherBLUE CROSS BLUE SHIELD
FLE70303Medicare UPIN