Provider Demographics
NPI:1790134021
Name:WEATHERS, JOHN JR (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:WEATHERS
Suffix:JR
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 1:6342 SYLVESTER ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19149-2836
Mailing Address - Country:US
Mailing Address - Phone:225-773-9323
Mailing Address - Fax:
Practice Address - Street 1:1500 MARKET PLACE BLVD
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-6060
Practice Address - Country:US
Practice Address - Phone:770-888-2323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002948152W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program