Provider Demographics
NPI:1790766426
Name:WEAVER, DAVID E (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:E
Last Name:WEAVER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:DAVID
Other - Middle Name:
Other - Last Name:WEAVER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:1212 HAYWOOD RD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-2200
Mailing Address - Country:US
Mailing Address - Phone:864-234-7700
Mailing Address - Fax:864-288-7180
Practice Address - Street 1:1212 HAYWOOD RD
Practice Address - Street 2:SUITE 600
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-2200
Practice Address - Country:US
Practice Address - Phone:864-234-7700
Practice Address - Fax:864-288-7180
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC569152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC569OtherPROFESSIONAL
SCDO5698Medicaid
SCU312915583Medicare ID - Type UnspecifiedMEDICARE
SCU31291Medicare UPIN