Provider Demographics
NPI:1548244700
Name:WEAVER, BRUCE MARSHALL (DO)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:MARSHALL
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 1:6542 SINISI DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-7069
Mailing Address - Country:US
Mailing Address - Phone:352-729-1375
Mailing Address - Fax:
Practice Address - Street 1:6542 SINISI DR
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-7069
Practice Address - Country:US
Practice Address - Phone:352-729-1375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-01
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9691207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLEI541YMedicare Oscar/Certification