Provider Demographics
NPI:1851318331
Name:WEAVER, JONATHAN DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DOUGLAS
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 1:2121 WILSHIRE BLVD
Mailing Address - Street 2:#304
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403
Mailing Address - Country:US
Mailing Address - Phone:310-264-0065
Mailing Address - Fax:310-829-0765
Practice Address - Street 1:2121 WILSHIRE BLVD
Practice Address - Street 2:#103
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403
Practice Address - Country:US
Practice Address - Phone:310-264-0065
Practice Address - Fax:310-829-3424
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA81411207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA81411BMedicare ID - Type Unspecified
I04614Medicare UPIN