Provider Demographics
NPI:1689638058
Name:WEAVER, JOHN BENNETT II (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BENNETT
Last Name:WEAVER
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:189 GOURGE RD
Mailing Address - Street 2:
Mailing Address - City:HENAGAR
Mailing Address - State:AL
Mailing Address - Zip Code:35978-5119
Mailing Address - Country:US
Mailing Address - Phone:205-300-2710
Mailing Address - Fax:256-845-4499
Practice Address - Street 1:1906 GLENN BLVD SW
Practice Address - Street 2:
Practice Address - City:FORT PAYNE
Practice Address - State:AL
Practice Address - Zip Code:35968-3545
Practice Address - Country:US
Practice Address - Phone:256-845-7555
Practice Address - Fax:256-845-4499
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL00013008207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009951580Medicaid
AL051501152Medicare PIN
AL009951580Medicaid