Provider Demographics
NPI:1912911371
Name:WEAVER, RICHARD J (DC)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:J
Last Name:WEAVER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:NAZARETH
Mailing Address - State:PA
Mailing Address - Zip Code:18064
Mailing Address - Country:US
Mailing Address - Phone:610-393-1440
Mailing Address - Fax:
Practice Address - Street 1:83 BANGOR JUNCTION ROAD
Practice Address - Street 2:BLUE VALLEY PLAZA
Practice Address - City:BANGOR
Practice Address - State:PA
Practice Address - Zip Code:18013
Practice Address - Country:US
Practice Address - Phone:610-588-7640
Practice Address - Fax:610-588-7114
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC007215L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA02783600OtherCAPITAL BC
PA2215248OtherAETNA
PA557504OtherBLUE SHIELD
PA768867OtherBLUE SHIELD
PA557504OtherBLUE SHIELD
PA768867OtherBLUE SHIELD