Provider Demographics
NPI:1801927140
Name:STEVEN J. WEAVER, O.D. LLC
Entity type:Organization
Organization Name:STEVEN J. WEAVER, O.D. LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:802-756-7150
Mailing Address - Street 1:11038 HIGHLAND BLVD
Mailing Address - Street 2:#300
Mailing Address - City:HIGHLAND
Mailing Address - State:UT
Mailing Address - Zip Code:84003-3785
Mailing Address - Country:US
Mailing Address - Phone:801-756-7150
Mailing Address - Fax:801-642-0938
Practice Address - Street 1:11038 HIGHLAND BLVD
Practice Address - Street 2:#300
Practice Address - City:HIGHLAND
Practice Address - State:UT
Practice Address - Zip Code:84003-3785
Practice Address - Country:US
Practice Address - Phone:801-756-7150
Practice Address - Fax:801-642-0938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT328345-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT519172164003Medicaid
UT519172164004Medicaid
UT519172164001Medicaid
UTU96004Medicare UPIN
UT519172164004Medicaid