Provider Demographics
NPI:1154909984
Name:WESLEY, JOHN (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WESLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 NAPIER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-2112
Mailing Address - Country:US
Mailing Address - Phone:269-982-4941
Mailing Address - Fax:
Practice Address - Street 1:1234 NAPIER AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085
Practice Address - Country:US
Practice Address - Phone:269-982-4941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-01
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4301510522207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program