Provider Demographics
NPI:1306962519
Name:JAMES R WEAGLEY, MD, INC.
Entity type:Organization
Organization Name:JAMES R WEAGLEY, MD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:WEAGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-324-4625
Mailing Address - Street 1:20280 SORRENTO LN APT 208
Mailing Address - Street 2:
Mailing Address - City:PORTER RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:91326-4482
Mailing Address - Country:US
Mailing Address - Phone:818-324-4625
Mailing Address - Fax:
Practice Address - Street 1:24355 LYONS AVE
Practice Address - Street 2:SUITE 130
Practice Address - City:NEWHALL
Practice Address - State:CA
Practice Address - Zip Code:91321-2300
Practice Address - Country:US
Practice Address - Phone:661-255-9355
Practice Address - Fax:661-255-7951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA046229207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA46229OtherMED LICENSE
CACEO52AMedicare PIN
CAA46229OtherMED LICENSE
E27236Medicare UPIN