Provider Demographics
NPI:1225127178
Name:WEAVER, SCOTT ALAN (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:ALAN
Last Name:WEAVER
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 1:3500 N INTERSTATE AVE
Mailing Address - Street 2:INTERSTATE MEDICAL OFFICE SOUTH
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1196
Mailing Address - Country:US
Mailing Address - Phone:503-333-1615
Mailing Address - Fax:503-331-6145
Practice Address - Street 1:3500 N INTERSTATE AVE
Practice Address - Street 2:INTERSTATE MEDICAL OFFICE SOUTH
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1196
Practice Address - Country:US
Practice Address - Phone:503-333-1615
Practice Address - Fax:503-331-6145
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD179642085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology