Healthcare Provider Details

I. General information

NPI: 1609867738
Provider Name (Legal Business Name): WENDY EVE WEISS DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: WENDY EVE DASILVA D.O.

II. Dates (important events)

Enumeration Date: 10/28/2005
Last Update Date: 04/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 PRICE ST SUITE 101
PISMO BEACH CA
93449-2553
US

IV. Provider business mailing address

575 PRICE ST SUITE 101
PISMO BEACH CA
93449-2553
US

V. Phone/Fax

Practice location:
  • Phone: 805-773-0707
  • Fax: 805-773-2051
Mailing address:
  • Phone: 805-773-0707
  • Fax: 805-773-2051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A6436
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: