Provider Demographics
NPI:1346206562
Name:WEAVER, AMY (OD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:WEAVER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4805 S MOORLAND RD
Mailing Address - Street 2:F&MCW COMMUNITY PHYSICIANS MOORLAND RESERVE
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-7401
Mailing Address - Country:US
Mailing Address - Phone:262-798-7200
Mailing Address - Fax:
Practice Address - Street 1:N14W23900 STONE RIDGE DR
Practice Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-1135
Practice Address - Country:US
Practice Address - Phone:262-549-3030
Practice Address - Fax:262-574-7833
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2572152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38597800Medicaid
WIU57098Medicare UPIN
WI38597800Medicaid