Provider Demographics
NPI:1962660704
Name:WEAVER, DEREK SAMUEL (DO)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:SAMUEL
Last Name:WEAVER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2935 ALLEN RD
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:WA
Mailing Address - Zip Code:98944-8931
Mailing Address - Country:US
Mailing Address - Phone:509-837-0070
Mailing Address - Fax:509-837-0690
Practice Address - Street 1:2935 ALLEN RD
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:WA
Practice Address - Zip Code:98944-8931
Practice Address - Country:US
Practice Address - Phone:509-837-0070
Practice Address - Fax:509-837-0690
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP60139736207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1962660704Medicaid