Provider Demographics
NPI:1871639898
Name:WEISEL, JOHN C (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:C
Last Name:WEISEL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1814 LINCOLN WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2540
Mailing Address - Country:US
Mailing Address - Phone:208-667-2531
Mailing Address - Fax:208-765-9385
Practice Address - Street 1:1814 LINCOLN WAY
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2540
Practice Address - Country:US
Practice Address - Phone:208-667-2531
Practice Address - Fax:208-765-9385
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP970152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1592894OtherMEDICARE GROUP
HIV9709OtherBLUE CROSS OF IDAHO
ID1592883OtherMEDICARE
ID000010015493OtherREGENCE BLUE SHIELD OF ID
ID804004300Medicaid
ID1592894OtherMEDICARE GROUP
ID1592883OtherMEDICARE
ID1592894OtherMEDICARE GROUP