Healthcare Provider Details

I. General information

NPI: 1629072053
Provider Name (Legal Business Name): JON-MARC WESTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 12/09/2020
Certification Date: 12/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2435 NW KLINE ST
ROSEBURG OR
97471-1690
US

IV. Provider business mailing address

2435 NW KLINE ST
ROSEBURG OR
97471-1690
US

V. Phone/Fax

Practice location:
  • Phone: 541-672-2020
  • Fax: 541-673-8084
Mailing address:
  • Phone: 541-672-2020
  • Fax: 541-673-8084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number17072
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: