Provider Demographics
NPI:1184640922
Name:WEBER, RICHARD J (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:J
Last Name:WEBER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 BEVERLY DR
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-2833
Mailing Address - Country:US
Mailing Address - Phone:321-632-1520
Mailing Address - Fax:321-632-6874
Practice Address - Street 1:1007 BEVERLY DR
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2833
Practice Address - Country:US
Practice Address - Phone:321-632-1520
Practice Address - Fax:321-632-6874
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0036374207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL039654100Medicaid
FL039654100Medicaid
FL47352Medicare UPIN