Provider Demographics
NPI:1548265002
Name:WEAVER-OSTERHOLTZ, DANA J (MD)
Entity type:Individual
Prefix:MRS
First Name:DANA
Middle Name:J
Last Name:WEAVER-OSTERHOLTZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4740 KATAHDIN LN
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004
Mailing Address - Country:US
Mailing Address - Phone:719-676-3728
Mailing Address - Fax:
Practice Address - Street 1:4740 KATAHDIN LN
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004
Practice Address - Country:US
Practice Address - Phone:719-676-3728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-20
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO40134174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO48477877Medicaid
CO365248Medicare ID - Type UnspecifiedMEDICARE
COA13718Medicare UPIN