Provider Demographics
NPI:1568565349
Name:WEAVER, BRIAN JOSEPH (OD, MBA)
Entity Type:Individual
Prefix:PROF
First Name:BRIAN
Middle Name:JOSEPH
Last Name:WEAVER
Suffix:
Gender:M
Credentials:OD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17275 MORNINGVIEW CT
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-4358
Mailing Address - Country:US
Mailing Address - Phone:262-391-8833
Mailing Address - Fax:
Practice Address - Street 1:4419 N SHEFFIELD AVE
Practice Address - Street 2:
Practice Address - City:SHOREWOOD
Practice Address - State:WI
Practice Address - Zip Code:53211-1307
Practice Address - Country:US
Practice Address - Phone:262-391-8112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTPOP110152W00000X
WI2800152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38630700Medicaid
WIT01415Medicare UPIN