MEDICARE: MR. GARY LOUIS WEITEKAMP DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DN0009503	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	547422	OTHER		UNITED CONCORDIA INS CO

General Provider Information

NPI Number	:	1396958005
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GARY LOUIS WEITEKAMP DDS

Provider Business Mailing Address
First Line	:	2407 ST ANDREWS BLVD
Second Line	:	SUITE A
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-2170
Country	:	US
Telephone Number	:	850-763-5021
Fax Number	:	850-769-5025

Provider Business Practice Location Address
First Line	:	2407 ST ANDREWS BLVD
Second Line	:	SUITE A
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-2170
Country	:	US
Telephone Number	:	850-763-5021
Fax Number	:	850-769-5025

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/08/2007
Last Update Date	:	07/08/2007

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