Provider Demographics
NPI:1134358880
Name:WEBER, MYRA RENEE (OD)
Entity type:Individual
Prefix:DR
First Name:MYRA
Middle Name:RENEE
Last Name:WEBER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:MYRA
Other - Middle Name:RENEE
Other - Last Name:BAUMGARTNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:4626 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6897
Mailing Address - Country:US
Mailing Address - Phone:260-432-5502
Mailing Address - Fax:260-432-8415
Practice Address - Street 1:4626 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6897
Practice Address - Country:US
Practice Address - Phone:260-432-5502
Practice Address - Fax:260-432-8415
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-02
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003594A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00959074OtherPROVIDER PTAN