Healthcare Provider Details

I. General information

NPI: 1144882879
Provider Name (Legal Business Name): THEODORE C WEATHERWAX MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2019
Last Update Date: 11/23/2022
Certification Date: 11/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST
BOSTON MA
02114-2621
US

IV. Provider business mailing address

2209 E 32ND ST
TACOMA WA
98404-4922
US

V. Phone/Fax

Practice location:
  • Phone: 617-726-3557
  • Fax:
Mailing address:
  • Phone: 253-593-0232
  • Fax: 253-593-3311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMDRE.ML.60958797
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number291350
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: