Basic Information
| Provider Information | |||||||||
| NPI: | 1245506195 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEIVODA | ||||||||
| FirstName: | STARCHILD | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2050 S BLOSSER RD | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934587310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8053618030 | ||||||||
| FaxNumber: | 8053618097 | ||||||||
| Practice Location | |||||||||
| Address1: | 4711 HIGHWAY 166 | ||||||||
| Address2: | |||||||||
| City: | NEW CUYAMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6617662149 | ||||||||
| FaxNumber: | 6617662350 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2012 | ||||||||
| LastUpdateDate: | 10/15/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 02004645A | IN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 18475 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 201320520 | 05 | IN | MEDICAID | 1647495 | 05 | AK | MEDICAID |