Provider Demographics
NPI:1679578504
Name:WEAVER, DAVID J (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:WEAVER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2200 E PARRISH AVE
Mailing Address - Street 2:BLDG D SUITE 100
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-1449
Mailing Address - Country:US
Mailing Address - Phone:270-688-1770
Mailing Address - Fax:270-688-1781
Practice Address - Street 1:2200 E PARRISH AVE
Practice Address - Street 2:BLDG D SUITE 100
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-1449
Practice Address - Country:US
Practice Address - Phone:270-688-1770
Practice Address - Fax:270-688-1781
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
174400000X
IN01060207A207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200510920Medicaid