Provider Demographics
NPI:1609141233
Name:WEAVER, KYLE JONATHAN (OD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:JONATHAN
Last Name:WEAVER
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 1:4100 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45428-9000
Mailing Address - Country:US
Mailing Address - Phone:260-729-2311
Mailing Address - Fax:
Practice Address - Street 1:2740 NAVARRE AVE
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616
Practice Address - Country:US
Practice Address - Phone:419-693-4444
Practice Address - Fax:419-697-2149
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-15
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003711A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0233917Medicaid