Provider Demographics
NPI:1376748491
Name:WEAVER, KATHLEEN M (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:M
Last Name:WEAVER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 E SUMMIT ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:MEXICO
Mailing Address - State:MO
Mailing Address - Zip Code:65265-3298
Mailing Address - Country:US
Mailing Address - Phone:573-582-0444
Mailing Address - Fax:573-582-0438
Practice Address - Street 1:626 E SUMMIT ST
Practice Address - Street 2:SUITE B
Practice Address - City:MEXICO
Practice Address - State:MO
Practice Address - Zip Code:65265-3298
Practice Address - Country:US
Practice Address - Phone:573-582-0444
Practice Address - Fax:573-582-0438
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000161967207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
F67119Medicare UPIN