Provider Demographics
NPI:1861454241
Name:WEAVER, BRENDON J (OD)
Entity Type:Individual
Prefix:
First Name:BRENDON
Middle Name:J
Last Name:WEAVER
Suffix:
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 1:7185 BERNVILLE RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:BERNVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19506-8624
Mailing Address - Country:US
Mailing Address - Phone:610-488-5315
Mailing Address - Fax:610-488-5296
Practice Address - Street 1:7185 BERNVILLE RD
Practice Address - Street 2:SUITE B
Practice Address - City:BERNVILLE
Practice Address - State:PA
Practice Address - Zip Code:19506-8624
Practice Address - Country:US
Practice Address - Phone:610-488-5315
Practice Address - Fax:610-488-5296
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001233152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50053706OtherCAPITAL BLUE CROSS
PA7964550OtherAETNA
PA2397071OtherUNITED HEALTHCARE
PA1009637000001Medicaid
2277395000OtherINDEPENDENCE BLUE CROSS
PA1598378OtherHIGHMARK BLUE SHIELD
PA079445Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
PAU98053Medicare UPIN