Provider Demographics
NPI:1366577744
Name:JOHN C WEAVER MD A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:JOHN C WEAVER MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-724-8164
Mailing Address - Street 1:PO BOX 424
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-0424
Mailing Address - Country:US
Mailing Address - Phone:323-724-8164
Mailing Address - Fax:323-724-9207
Practice Address - Street 1:204 S ATLANTIC BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-1755
Practice Address - Country:US
Practice Address - Phone:323-724-8164
Practice Address - Fax:323-724-9207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG35959208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW17133Medicare ID - Type Unspecified
CA406104Medicare UPIN