Provider Demographics
NPI:1205845187
Name:WEBER, J DAVID (OD)
Entity Type:Individual
Prefix:DR
First Name:J
Middle Name:DAVID
Last Name:WEBER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 HWY. 50
Mailing Address - Street 2:WALMART VISION CENTER
Mailing Address - City:O'FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269
Mailing Address - Country:US
Mailing Address - Phone:618-628-7064
Mailing Address - Fax:618-628-7296
Practice Address - Street 1:1530 HWY. 50
Practice Address - Street 2:WALMART VISION CENTER
Practice Address - City:O'FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269
Practice Address - Country:US
Practice Address - Phone:618-628-7064
Practice Address - Fax:618-628-7296
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist