Provider Demographics
NPI:1295722080
Name:WEAVER, MARK E (DPM)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:WEAVER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1645 COLONIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1101
Mailing Address - Country:US
Mailing Address - Phone:239-278-4448
Mailing Address - Fax:239-939-1286
Practice Address - Street 1:1645 COLONIAL BLVD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-1101
Practice Address - Country:US
Practice Address - Phone:239-278-4448
Practice Address - Fax:239-939-1286
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-05
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO00001857213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL87996OtherBCBS
FL87996Medicare PIN
FLU00870Medicare UPIN
FL0859470001Medicare NSC