Provider Demographics
NPI:1215995097
Name:WEAVER, MICHAEL JAMES (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JAMES
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 1:553 KINGSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02879-3600
Mailing Address - Country:US
Mailing Address - Phone:401-304-9111
Mailing Address - Fax:401-284-0625
Practice Address - Street 1:553 KINGSTOWN RD
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:RI
Practice Address - Zip Code:02879-3600
Practice Address - Country:US
Practice Address - Phone:401-304-9111
Practice Address - Fax:401-284-0625
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI05003208600000X
RI5003207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIMW01082Medicaid
RIMW01082Medicaid
RI007057503Medicare PIN