Provider Demographics
NPI:1609395854
Name:WEBER PODIATRY LLC
Entity Type:Organization
Organization Name:WEBER PODIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIERSTEN
Authorized Official - Middle Name:B
Authorized Official - Last Name:WEBER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:405-819-1182
Mailing Address - Street 1:PO BOX 8373
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73083-8373
Mailing Address - Country:US
Mailing Address - Phone:1405-819-1182
Mailing Address - Fax:
Practice Address - Street 1:1501 AUTUMN CREEK DR
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73003-3500
Practice Address - Country:US
Practice Address - Phone:405-819-1182
Practice Address - Fax:405-285-8921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-19
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK212261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200180850AMedicaid