Provider Demographics
NPI:1417989344
Name:WEAVER, FRED A (MD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:A
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:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-442-5849
Mailing Address - Fax:
Practice Address - Street 1:1520 SAN PABLO ST
Practice Address - Street 2:SUITE 4300
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5330
Practice Address - Country:US
Practice Address - Phone:323-442-5849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG574872086S0129X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G574870Medicaid
CA00G574870C29OtherCAL OPTIMA PIN
CAP00388728OtherMEDICARE RAILROAD PIN
CA00G574870OtherBLUE SHIELD PIN
CA020023707OtherMEDICARE RAILROAD PIN
CABP208ZMedicare PIN
CAWG57487AMedicare PIN
CA00G574870OtherBLUE SHIELD PIN
A53292Medicare UPIN
CAP00388728OtherMEDICARE RAILROAD PIN