Healthcare Provider Details

I. General information

NPI: 1881839389
Provider Name (Legal Business Name): DAVID WEYMOUTH CPO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2008
Last Update Date: 03/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1745 W KETTLEMAN LN SUITE A
LODI CA
95242-9287
US

IV. Provider business mailing address

4583 PINE VALLEY CIR
STOCKTON CA
95219-1871
US

V. Phone/Fax

Practice location:
  • Phone: 209-333-2259
  • Fax: 209-333-0624
Mailing address:
  • Phone: 209-474-2646
  • Fax: 209-333-0624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberCPO1776
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: