=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932310406
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SARATOGA WALK IN CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2007
-----------------------------------------------------
Last Update Date | 02/01/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12224 SARATOGA SUNNYVALE ROAD
-----------------------------------------------------
City | SARATOGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-446-4774
-----------------------------------------------------
Fax | 408-446-9422
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14054 ALTA VISTA AVENUE
-----------------------------------------------------
City | SARATOGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-867-1007
-----------------------------------------------------
Fax | 408-867-4459
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER MEDICAL DIRECTOR
-----------------------------------------------------
Name | DAVID G WETTERHOLT
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 408-446-4774
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | G24402
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------