Provider Demographics
NPI:1689655771
Name:WEAVER, DAVID L
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:L
Last Name:WEAVER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12087
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23612-2087
Mailing Address - Country:US
Mailing Address - Phone:757-867-6101
Mailing Address - Fax:757-867-6587
Practice Address - Street 1:500 J CLYDE MORRIS BLVD
Practice Address - Street 2:RIVERSIDE REGIONAL MEDICAL CENTER
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-1929
Practice Address - Country:US
Practice Address - Phone:757-594-4405
Practice Address - Fax:757-594-3547
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME846432085R0202X
VA01010341332085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010264405Medicaid
FL17354OtherBCBS
FL264087100Medicaid
VA1689655771Medicaid
VAP00468522OtherRAILROAD MEDICARE PIN
VA010161M41Medicare ID - Type UnspecifiedC03041
VA010264405Medicaid
B97226Medicare UPIN
FL17354OtherBCBS