Healthcare Provider Details

I. General information

NPI: 1275570897
Provider Name (Legal Business Name): JERRY L WEED JR. DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 07/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 US 1 S
ST AUGUSTINE FL
32086-7150
US

IV. Provider business mailing address

130 HEALTH PARK BLVD
ST AUGUSTINE FL
32086-5776
US

V. Phone/Fax

Practice location:
  • Phone: 904-429-4736
  • Fax:
Mailing address:
  • Phone: 904-547-2808
  • Fax: 904-679-3169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPO3003
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: