Provider Demographics
NPI:1023185121
Name:WEAVER, DOUGLAS E (DC)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:E
Last Name:WEAVER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7100 MENAUL BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-3688
Mailing Address - Country:US
Mailing Address - Phone:505-883-5858
Mailing Address - Fax:505-883-0010
Practice Address - Street 1:7100 MENAUL BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-3688
Practice Address - Country:US
Practice Address - Phone:505-883-5858
Practice Address - Fax:505-883-0010
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM540111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMK7060Medicaid
NM2671525Medicare PIN