=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053379677
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WESLEY OWEN YEACKLE M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2006
-----------------------------------------------------
Last Update Date | 04/30/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4263 OCEANSIDE BLVD SUITE #106-163
-----------------------------------------------------
City | OCEANSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92056-3479
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-277-5214
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4263 OCEANSIDE BLVD SUITE #106-163
-----------------------------------------------------
City | OCEANSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92056-3479
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-277-5214
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2083A0100X
-----------------------------------------------------
Taxonomy Name | Aerospace Medicine Physician
-----------------------------------------------------
License Number | 01056653A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2083P0011X
-----------------------------------------------------
Taxonomy Name | Undersea and Hyperbaric Medicine (Preventive Medicine) Physician
-----------------------------------------------------
License Number | 01056653A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | C129122
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------