Provider Demographics
NPI:1588639264
Name:WEAVER, MARY ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:WEAVER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1052 ROSS CLARK CIRCLE
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303
Mailing Address - Country:US
Mailing Address - Phone:334-699-3600
Mailing Address - Fax:334-699-3601
Practice Address - Street 1:1052 ROSS CLARK CIRCLE
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303
Practice Address - Country:US
Practice Address - Phone:334-699-3600
Practice Address - Fax:334-699-3601
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL10454207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1757306Medicaid
AL051515759Medicaid
MS05781000Medicaid
AL51515759OtherBLUE CROSS BLUE SHIELD
GA000303619DMedicaid
FL042556700Medicaid
P00055590OtherRAILROAD MEDICARE
GA000303619DMedicaid
P00055590OtherRAILROAD MEDICARE
MS05781000Medicaid