Provider Demographics
NPI:1255447900
Name:WEAVER, DONALD D (MD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:D
Last Name:WEAVER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:DONALD
Other - Middle Name:
Other - Last Name:WEAVER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:30 S. CLINTON ST.
Mailing Address - Street 2:SUITE 7205
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-2497
Mailing Address - Country:US
Mailing Address - Phone:509-522-1358
Mailing Address - Fax:
Practice Address - Street 1:1612 31ST AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2750
Practice Address - Country:US
Practice Address - Phone:228-864-8454
Practice Address - Fax:228-865-1457
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2009-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14403207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS110136321OtherRAILROAD MEDICARE
MS00114891Medicaid
MS110136321OtherRAILROAD MEDICARE
MS110136321OtherRAILROAD MEDICARE
MSD75045Medicare UPIN
MS512I080246Medicare PIN