Provider Demographics
NPI:1336604453
Name:WESTON, MICHAEL G
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:WESTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1944 LINDA LN
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39213-4447
Mailing Address - Country:US
Mailing Address - Phone:601-383-7087
Mailing Address - Fax:601-366-3090
Practice Address - Street 1:1944 LINDA LN
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213-4447
Practice Address - Country:US
Practice Address - Phone:601-383-7087
Practice Address - Fax:601-366-3090
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-02
Last Update Date:2019-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS802422810172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver