Provider Demographics
NPI:1497785893
Name:WEAVER, BLAKE (DO)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:WEAVER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 S BRYANT AVE
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-5742
Mailing Address - Country:US
Mailing Address - Phone:405-348-1900
Mailing Address - Fax:405-348-0423
Practice Address - Street 1:902 S BRYANT AVE
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-5742
Practice Address - Country:US
Practice Address - Phone:405-348-1900
Practice Address - Fax:405-348-0423
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4267207P00000X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200058090AMedicaid
OKI13406Medicare UPIN
OKI13406Medicare UPIN