MEDICARE: DR. JACOB ALAN WEATHERLY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	A150920	CA

General Provider Information

NPI Number	:	1538520457
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACOB ALAN WEATHERLY MD

Provider Business Mailing Address
First Line	:	6699 ALVARADO RD STE 2200
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92120-5253
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6699 ALVARADO RD STE 2200
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92120-5253
Country	:	US
Telephone Number	:	619-265-3400
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/20/2016
Last Update Date	:	06/19/2023

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