Provider Demographics
NPI:1972596518
Name:WEIR, JOHN C (OD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:C
Last Name:WEIR
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 1:849 3RD AVE W
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-3810
Mailing Address - Country:US
Mailing Address - Phone:701-483-2200
Mailing Address - Fax:
Practice Address - Street 1:849 3RD AVE W
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-3810
Practice Address - Country:US
Practice Address - Phone:701-483-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-30
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND459152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND60626Medicaid
ND711791Medicare ID - Type Unspecified
ND60626Medicaid