Provider Demographics
NPI:1801112503
Name:WEAVER, MARVIN V IV (MD)
Entity type:Individual
Prefix:
First Name:MARVIN
Middle Name:V
Last Name:WEAVER
Suffix:IV
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 1:8888 SUMMA AVE
Mailing Address - Street 2:CARDIOLOGY TOWER 3RD FLOOR
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-3720
Mailing Address - Country:US
Mailing Address - Phone:225-769-4493
Mailing Address - Fax:
Practice Address - Street 1:8888 SUMMA AVE
Practice Address - Street 2:CARDIOLOGY TOWER 3RD FLOOR
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3720
Practice Address - Country:US
Practice Address - Phone:225-769-4493
Practice Address - Fax:225-766-3144
Is Sole Proprietor?:No
Enumeration Date:2010-04-20
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2076752086S0129X, 2086S0129X
NY2692362086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2387405Medicaid