Provider Demographics
NPI:1568563484
Name:WEBER, BRIAN EDWARD (OD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:EDWARD
Last Name:WEBER
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:PO BOX 1326
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45501-1326
Mailing Address - Country:US
Mailing Address - Phone:937-325-5045
Mailing Address - Fax:937-717-6905
Practice Address - Street 1:21 E WARD ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45504-2203
Practice Address - Country:US
Practice Address - Phone:937-325-5045
Practice Address - Fax:937-717-6905
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4151152W00000X, 152WC0802X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4151OtherSTATE LICENSE NUMBER
OH4151OtherSTATE LICENSE NUMBER
OHU40512Medicare UPIN
OH5354040001Medicare NSC