Provider Demographics
NPI:1548966427
Name:WEATHERSBY, REID GUILLORY (IDC)
Entity type:Individual
Prefix:
First Name:REID
Middle Name:GUILLORY
Last Name:WEATHERSBY
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34101 FARENHOLT AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-7000
Mailing Address - Country:US
Mailing Address - Phone:404-725-5619
Mailing Address - Fax:
Practice Address - Street 1:639 19TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-2805
Practice Address - Country:US
Practice Address - Phone:404-725-5619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman