Provider Demographics
NPI:1801292016
Name:WEAVER, OTIS (LICENSED OPTICIAN)
Entity type:Individual
Prefix:MR
First Name:OTIS
Middle Name:
Last Name:WEAVER
Suffix:
Gender:M
Credentials:LICENSED OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5391 RADFORD LN
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-2899
Mailing Address - Country:US
Mailing Address - Phone:404-219-4309
Mailing Address - Fax:
Practice Address - Street 1:4765 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-1417
Practice Address - Country:US
Practice Address - Phone:404-296-2307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-16
Last Update Date:2014-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO001204156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician