Provider Demographics
NPI:1487121943
Name:KINGWOOD DIRECT MD LLC
Entity type:Organization
Organization Name:KINGWOOD DIRECT MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAUN
Authorized Official - Middle Name:
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:832-445-5641
Mailing Address - Street 1:24 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77339-3709
Mailing Address - Country:US
Mailing Address - Phone:281-570-6758
Mailing Address - Fax:832-777-6282
Practice Address - Street 1:24 N MAIN ST
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77339-3709
Practice Address - Country:US
Practice Address - Phone:281-570-6758
Practice Address - Fax:832-777-6282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-01
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty