Provider Demographics
NPI:1689779712
Name:WEAVER, JEFFREY LANCE (OD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:LANCE
Last Name:WEAVER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3662 BOSTONS FARM DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-3167
Mailing Address - Country:US
Mailing Address - Phone:314-952-2226
Mailing Address - Fax:314-228-2020
Practice Address - Street 1:1200 W GODFREY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3323
Practice Address - Country:US
Practice Address - Phone:215-276-6000
Practice Address - Fax:215-276-1329
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4248T125152W00000X
PAOEG003775152W00000X
MOT02793152W00000X
OR2042152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1689779712Medicaid
MO016300014Medicare PIN
MO1689779712Medicaid
U119982Medicare UPIN
MO051007473Medicare PIN