Healthcare Provider Details

I. General information

NPI: 1538520457
Provider Name (Legal Business Name): JACOB ALAN WEATHERLY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2016
Last Update Date: 06/19/2023
Certification Date: 06/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6699 ALVARADO RD STE 2200
SAN DIEGO CA
92120-5253
US

IV. Provider business mailing address

6699 ALVARADO RD STE 2200
SAN DIEGO CA
92120-5253
US

V. Phone/Fax

Practice location:
  • Phone: 619-265-3400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA150920
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: