Provider Demographics
NPI:1043363666
Name:JASON M. WEAVER, MD, PA
Entity Type:Organization
Organization Name:JASON M. WEAVER, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:979-575-7435
Mailing Address - Street 1:1602 ROCK PRAIRIE RD
Mailing Address - Street 2:SUITE 3400
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-8306
Mailing Address - Country:US
Mailing Address - Phone:979-575-7435
Mailing Address - Fax:
Practice Address - Street 1:1602 ROCK PRAIRIE RD
Practice Address - Street 2:SUITE 3400
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-8306
Practice Address - Country:US
Practice Address - Phone:409-939-1618
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207N00000X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty