Provider Demographics
NPI:1528387263
Name:WEAVER, MARTHA GOMEZ (RD, LDN)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:GOMEZ
Last Name:WEAVER
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19140-5103
Mailing Address - Country:US
Mailing Address - Phone:215-707-3811
Mailing Address - Fax:215-707-3959
Practice Address - Street 1:3401 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5103
Practice Address - Country:US
Practice Address - Phone:215-707-3811
Practice Address - Fax:215-707-3959
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-20
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN004035133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered