Provider Demographics
NPI:1457318586
Name:WEAVER, JOEL M (DDS PHD)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:M
Last Name:WEAVER
Suffix:
Gender:M
Credentials:DDS PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 W. TENTH AVE.
Mailing Address - Street 2:N411 DOAN HALL
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43210-1250
Mailing Address - Country:US
Mailing Address - Phone:614-293-8487
Mailing Address - Fax:614-293-8153
Practice Address - Street 1:410 WEST TENTH AVENUE
Practice Address - Street 2:N429 DOAN HALL
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210
Practice Address - Country:US
Practice Address - Phone:614-293-8487
Practice Address - Fax:614-293-8153
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.014176122300000X
OH30014176207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0408624Medicaid
T47381Medicare UPIN
WE0801343Medicare ID - Type Unspecified