Provider Demographics
NPI:1215198155
Name:WEATHERS, JOHN ROUSE (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ROUSE
Last Name:WEATHERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:336-766-0547
Mailing Address - Fax:336-766-0549
Practice Address - Street 1:105 STADIUM OAKS DR
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-8962
Practice Address - Country:US
Practice Address - Phone:336-766-0547
Practice Address - Fax:336-766-0549
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2012-00190208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5920486Medicaid
NCNC8068AMedicare PIN