=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134703366
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WESTON DAKOTA ELDRIDGE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2021
-----------------------------------------------------
Last Update Date | 02/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14724 HIGHWAY 15 N
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39339-6318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-773-7500
-----------------------------------------------------
Fax | 662-446-1698
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 98 SERENE HLS
-----------------------------------------------------
City | HATTIESBURG
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39402-8567
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 769-798-8991
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 30376
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------