Provider Demographics
NPI:1144283805
Name:WEATHERS, LUTHER BASEL III (MD)
Entity type:Individual
Prefix:
First Name:LUTHER
Middle Name:BASEL
Last Name:WEATHERS
Suffix:III
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 1:2233 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-3831
Mailing Address - Country:US
Mailing Address - Phone:970-765-0818
Mailing Address - Fax:970-497-8410
Practice Address - Street 1:702 N 13TH ST
Practice Address - Street 2:
Practice Address - City:ARTESIA
Practice Address - State:NM
Practice Address - Zip Code:88210-1199
Practice Address - Country:US
Practice Address - Phone:575-748-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM20020268207RC0000X
TXJ2409207RC0000X
CODR.0056382207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000W1015Medicaid
TX138693016Medicaid
NM000W1015Medicaid
TX138693016Medicaid