Provider Demographics
NPI:1407844962
Name:WEAVER, ALAN M (DO)
Entity Type:Individual
Prefix:MR
First Name:ALAN
Middle Name:M
Last Name:WEAVER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:6601 W THORNHILL RD
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:MO
Mailing Address - Zip Code:65243-9381
Mailing Address - Country:US
Mailing Address - Phone:573-641-5019
Mailing Address - Fax:573-687-3328
Practice Address - Street 1:208 N OGDEN ST
Practice Address - Street 2:
Practice Address - City:STURGEON
Practice Address - State:MO
Practice Address - Zip Code:65284-9217
Practice Address - Country:US
Practice Address - Phone:573-687-3411
Practice Address - Fax:573-687-3328
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-10
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8G92207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO242429009Medicaid
MO000094626Medicare ID - Type Unspecified
MOA14027Medicare UPIN