Provider Demographics
NPI:1316948920
Name:WEAVER, JANE M (MD)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:M
Last Name:WEAVER
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 1:11141 PARKVIEW PLAZA DR STE 305
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1715
Mailing Address - Country:US
Mailing Address - Phone:260-484-9611
Mailing Address - Fax:260-484-1004
Practice Address - Street 1:11141 PARKVIEW PLAZA DR STE 305
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1715
Practice Address - Country:US
Practice Address - Phone:260-484-9611
Practice Address - Fax:260-484-1004
Is Sole Proprietor?:No
Enumeration Date:2005-08-04
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01049799A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200196440Medicaid
IN020041807OtherMEDICARE RAILROAD
OH2107455Medicaid
MI104435211Medicaid
MI104435211Medicaid
IN149110LMedicare PIN
IN020041807Medicare PIN
IN260100NMedicare PIN
IN020041807OtherMEDICARE RAILROAD
IN667640LMedicare PIN