Provider Demographics
NPI:1730167370
Name:WEINER, PAUL DAVID
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:DAVID
Last Name:WEINER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:PAUL
Other - Middle Name:DAVID
Other - Last Name:WEINER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:480 REDWOOD ST
Mailing Address - Street 2:SUITE 10
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-2958
Mailing Address - Country:US
Mailing Address - Phone:707-643-3687
Mailing Address - Fax:707-643-3077
Practice Address - Street 1:480 REDWOOD ST
Practice Address - Street 2:SUITE 10
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-2958
Practice Address - Country:US
Practice Address - Phone:707-643-3687
Practice Address - Fax:707-643-3077
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-04
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3880213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E38800Medicaid
U56586Medicare UPIN
CA1191110001Medicare NSC
CA000E38800Medicaid