Provider Demographics
NPI:1669465928
Name:WEAVER, RONALD S (MD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:S
Last Name:WEAVER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 AERICK ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-1978
Mailing Address - Country:US
Mailing Address - Phone:310-412-8181
Mailing Address - Fax:310-412-9299
Practice Address - Street 1:633 AERICK ST
Practice Address - Street 2:SUITE 101
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-1978
Practice Address - Country:US
Practice Address - Phone:310-412-8181
Practice Address - Fax:310-412-9299
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2013-08-14
Deactivation Date:2006-03-27
Deactivation Code:
Reactivation Date:2006-04-12
Provider Licenses
StateLicense IDTaxonomies
CAG30118207R00000X
CAWG30188A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG30188AMedicare PIN
CAG30118Medicare PIN