Provider Demographics
NPI:1952333221
Name:WEAVER, GERALD EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:EDWARD
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 1:176 1ST AVE N
Mailing Address - Street 2:OCEAN BEACH MEDICAL CLINIC
Mailing Address - City:ILWACO
Mailing Address - State:WA
Mailing Address - Zip Code:98624-9137
Mailing Address - Country:US
Mailing Address - Phone:360-642-3747
Mailing Address - Fax:360-642-3361
Practice Address - Street 1:176 1ST AVE N
Practice Address - Street 2:
Practice Address - City:ILWACO
Practice Address - State:WA
Practice Address - Zip Code:98624-9137
Practice Address - Country:US
Practice Address - Phone:360-642-3747
Practice Address - Fax:360-642-3361
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5731A208600000X
WAMD60398142208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1952333221Medicaid
WAG000802400OtherGROUP MC PTAN G000802400
WA1952333221Medicaid
WA503988Medicare Oscar/Certification