MEDICARE: DR. WENDY EVE WEISS DO

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	207Q00000X	Family Medicine Physician	20A6436	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	020A64360	OTHER	CA	BLUE SHIELD PIN

General Provider Information

NPI Number	:	1609867738
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WENDY EVE WEISS DO

Provider Business Mailing Address
First Line	:	575 PRICE ST
Second Line	:	SUITE 101
City	:	PISMO BEACH
State	:	CA
Zip	:	93449-2553
Country	:	US
Telephone Number	:	805-773-0707
Fax Number	:	805-773-2051

Provider Business Practice Location Address
First Line	:	575 PRICE ST
Second Line	:	SUITE 101
City	:	PISMO BEACH
State	:	CA
Zip	:	93449-2553
Country	:	US
Telephone Number	:	805-773-0707
Fax Number	:	805-773-2051

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

Provider Enumeration Date	:	10/28/2005
Last Update Date	:	04/05/2017

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