Provider Demographics
NPI:1487630588
Name:WEAVER, STEVEN J (OD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:J
Last Name:WEAVER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11038 HIGHLAND BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:UT
Mailing Address - Zip Code:84003-3788
Mailing Address - Country:US
Mailing Address - Phone:801-756-7150
Mailing Address - Fax:801-642-0938
Practice Address - Street 1:11038 HIGHLAND BLVD STE 300
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:UT
Practice Address - Zip Code:84003-3788
Practice Address - Country:US
Practice Address - Phone:801-756-7150
Practice Address - Fax:801-642-0938
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-20
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3283459934152W00000X
UT3283458904152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT$$$$$$$$$003Medicaid
UT$$$$$$$$$004Medicaid
UT$$$$$$$$$001Medicaid
UT$$$$$$$$$004Medicaid