Provider Demographics
NPI:1841508918
Name:JACK E WEAVER, MD PC
Entity type:Organization
Organization Name:JACK E WEAVER, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:E
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-682-7717
Mailing Address - Street 1:209 S 36TH ST
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-5043
Mailing Address - Country:US
Mailing Address - Phone:918-682-7717
Mailing Address - Fax:918-682-9434
Practice Address - Street 1:209 S 36TH ST
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-5043
Practice Address - Country:US
Practice Address - Phone:918-682-7717
Practice Address - Fax:918-682-9434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-22
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100088830AMedicaid
OK100088830AMedicaid