Provider Demographics
NPI:1528024882
Name:WEAVER, JAMES W (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:W
Last Name:WEAVER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1680 DUNLAWTON AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-4754
Mailing Address - Country:US
Mailing Address - Phone:386-304-1212
Mailing Address - Fax:386-304-8244
Practice Address - Street 1:1680 DUNLAWTON AVE
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-4754
Practice Address - Country:US
Practice Address - Phone:386-304-1212
Practice Address - Fax:386-304-8244
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00374452085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL068291800Medicaid
FL01292Medicare ID - Type Unspecified
FL068291800Medicaid