Provider Demographics
NPI:1083601009
Name:WEAVER, BENJAMIN WATSON (DPM)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:WATSON
Last Name:WEAVER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2081 N WEBB RD
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-3411
Mailing Address - Country:US
Mailing Address - Phone:316-269-3338
Mailing Address - Fax:316-264-5516
Practice Address - Street 1:1819 N GREENWICH RD
Practice Address - Street 2:SUITE B
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-3411
Practice Address - Country:US
Practice Address - Phone:316-269-3338
Practice Address - Fax:316-264-5516
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1200336213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS102715OtherBC/BS
KS100454970AMedicaid
KS102715OtherBC/BS
U93775Medicare UPIN