Provider Demographics
NPI:1053311191
Name:WEAVER, PAUL GERALD (DO)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:GERALD
Last Name:WEAVER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 WALLACE RD NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-3007
Mailing Address - Country:US
Mailing Address - Phone:503-371-3232
Mailing Address - Fax:503-375-2398
Practice Address - Street 1:1275 WALLACE RD NW
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304-3007
Practice Address - Country:US
Practice Address - Phone:503-371-3232
Practice Address - Fax:503-375-2398
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD016350207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR288192Medicaid
H05770Medicare UPIN
OR113412Medicare PIN