Provider Demographics
NPI:1245213248
Name:WEBER, EDWARD CHAS (DO)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:CHAS
Last Name:WEBER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7631 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4133
Mailing Address - Country:US
Mailing Address - Phone:260-436-7770
Mailing Address - Fax:260-436-3570
Practice Address - Street 1:7631 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4133
Practice Address - Country:US
Practice Address - Phone:260-436-7770
Practice Address - Fax:260-436-3570
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN020006712085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100328200Medicaid
137680CMedicare PIN
E03680Medicare UPIN