Healthcare Provider Details

I. General information

NPI: 1154323392
Provider Name (Legal Business Name): DONALD L WEESE JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 HILAND AVE STE H
BURLEY ID
83318-2688
US

IV. Provider business mailing address

PO BOX 30180
SALT LAKE CITY UT
84130-0180
US

V. Phone/Fax

Practice location:
  • Phone: 208-677-6266
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number33863
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberM-6230
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: