Provider Demographics
NPI:1316163892
Name:WEAVER, DANIEL RALPH (OD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:RALPH
Last Name:WEAVER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:7012 W BIRCHWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-3716
Mailing Address - Country:US
Mailing Address - Phone:847-647-9490
Mailing Address - Fax:484-303-9252
Practice Address - Street 1:1055 MCHENRY RD
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:IL
Practice Address - Zip Code:60090-2231
Practice Address - Country:US
Practice Address - Phone:847-215-2583
Practice Address - Fax:847-215-2584
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008142152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016-84635OtherBC-BS OF ILLINOIS
IL798620Medicare ID - Type UnspecifiedMEDICARE PART B
ILU46429Medicare UPIN