Provider Demographics
NPI:1194861021
Name:WEAVER, KIMBERLY M (MD)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:M
Last Name:WEAVER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:KIMBERLY
Other - Middle Name:M
Other - Last Name:HENNAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1312 NORTH HARVILLE RD
Mailing Address - Street 2:
Mailing Address - City:DUNCAN
Mailing Address - State:OK
Mailing Address - Zip Code:73533
Mailing Address - Country:US
Mailing Address - Phone:580-470-9800
Mailing Address - Fax:580-470-9802
Practice Address - Street 1:1312 NORTH HARVILLE RD
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:OK
Practice Address - Zip Code:73533
Practice Address - Country:US
Practice Address - Phone:580-470-9800
Practice Address - Fax:580-470-9802
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK24587207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200250690AMedicaid
OKOKB5671Medicare PIN