Provider Demographics
NPI:1437152634
Name:WEAVER, JOHN THOMAS (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:THOMAS
Last Name:WEAVER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:1315 W AUSTIN BLVD
Mailing Address - Street 2:APT B
Mailing Address - City:NEVADA
Mailing Address - State:MO
Mailing Address - Zip Code:64772-2803
Mailing Address - Country:US
Mailing Address - Phone:417-667-6119
Mailing Address - Fax:417-448-3643
Practice Address - Street 1:800 S ASH ST
Practice Address - Street 2:
Practice Address - City:NEVADA
Practice Address - State:MO
Practice Address - Zip Code:64772-3223
Practice Address - Country:US
Practice Address - Phone:417-448-3727
Practice Address - Fax:417-448-3643
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIJW008830208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIE36037Medicare UPIN
MI5690015-2-022Medicare ID - Type Unspecified