Provider Demographics
NPI:1699939751
Name:WEAVER, KRISTINE MARIE (OD)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:MARIE
Last Name:WEAVER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2393 SCHUST RD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-1334
Mailing Address - Country:US
Mailing Address - Phone:989-793-2820
Mailing Address - Fax:989-793-9132
Practice Address - Street 1:2393 SCHUST RD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603-1334
Practice Address - Country:US
Practice Address - Phone:989-793-2820
Practice Address - Fax:989-755-1463
Is Sole Proprietor?:No
Enumeration Date:2008-07-17
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004490152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1699939751Medicaid
382334055OtherTAX ID
900G310710OtherBLUE CROSS
382334055OtherTAX ID
900G310710OtherBLUE CROSS
N11610007Medicare PIN
MI1699939751Medicaid