Provider Demographics
NPI:1235187022
Name:WEIR, MICAH LORENZ (MD)
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:LORENZ
Last Name:WEIR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:MICHELLE
Other - Last Name:WEIR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 227143
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75222-7143
Mailing Address - Country:US
Mailing Address - Phone:800-841-4236
Mailing Address - Fax:985-646-0750
Practice Address - Street 1:120 CRICKET LN
Practice Address - Street 2:
Practice Address - City:NORTH ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01845-4837
Practice Address - Country:US
Practice Address - Phone:817-321-0404
Practice Address - Fax:469-522-6889
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM21912085R0204X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA11181013OtherCAQH
MA1235187022OtherSENIOR WHOLE HEALTH
MAAA135868OtherHARVARD PILGRIM HEALTH CARE
MA064507OtherTUFTS HEALTH PLAN
NH3096850Medicaid
MA2169185Medicaid
11181013OtherCAQH ID#
MA11181013OtherCAQH
MAJ44215OtherBLUE CROSS/BLUE SHIELD OF MASSACHUSETTS
NH3096850Medicaid