Provider Demographics
NPI:1164928685
Name:WEAVER, JOHN JOSEPH (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:JOSEPH
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 1:4N199 FOX MILL BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60175-7770
Mailing Address - Country:US
Mailing Address - Phone:630-479-9503
Mailing Address - Fax:
Practice Address - Street 1:3100 TONGASS AVE
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-5746
Practice Address - Country:US
Practice Address - Phone:907-228-4644
Practice Address - Fax:907-228-8337
Is Sole Proprietor?:No
Enumeration Date:2018-04-03
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2191792085R0202X
WAMD615498732085R0202X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program