Provider Demographics
NPI:1902802101
Name:WEAVER, JACK EUGENE (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:EUGENE
Last Name:WEAVER
Suffix:
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 1:209 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
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19721174400000X, 207Q00000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No174400000XOther Service ProvidersSpecialist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100088830AMedicaid
OK1841508918OtherGROUP NPI
OK1841508918OtherGROUP NPI
OK6346320001Medicare NSC