Provider Demographics
NPI:1558301614
Name:WEAVER, WILLIAM LEE (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:LEE
Last Name:WEAVER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4012 HEYWARD PL
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-4252
Mailing Address - Country:US
Mailing Address - Phone:317-840-8547
Mailing Address - Fax:
Practice Address - Street 1:801 N STATE ST
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:IN
Practice Address - Zip Code:46140-1270
Practice Address - Country:US
Practice Address - Phone:317-802-6301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01050939207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000594485OtherBLUE SHIELD
IN200244460Medicaid
IN200244460Medicaid
IN131180DDDMedicare PIN
IN142190YYMedicare PIN
H00630Medicare UPIN