Provider Demographics
NPI:1083880413
Name:WEAVER, MICHAEL DON (IDC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DON
Last Name:WEAVER
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PC CREW FOXTROT 40266
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09501-1915
Mailing Address - Country:US
Mailing Address - Phone:405-694-1049
Mailing Address - Fax:
Practice Address - Street 1:PC CREW FOXTROT 40266
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09501-1915
Practice Address - Country:US
Practice Address - Phone:405-694-1049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman