1609181916 NPI number — DR. ROBERT VINCENT WEAVER DMD

Table of content: DR. ROBERT VINCENT WEAVER DMD (NPI 1609181916)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609181916 NPI number — DR. ROBERT VINCENT WEAVER DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEAVER
Provider First Name:
ROBERT
Provider Middle Name:
VINCENT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609181916
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3020 HARTLEY RD
Provider Second Line Business Mailing Address:
SUITE #120
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32257
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-264-5437
Provider Business Mailing Address Fax Number:
904-485-8417

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
112 BARTRAM OAKS WALK
Provider Second Line Business Practice Location Address:
SUITE #203
Provider Business Practice Location Address City Name:
ST. JOHNS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32259
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-264-5437
Provider Business Practice Location Address Fax Number:
904-485-8417
Provider Enumeration Date:
08/11/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  DN18975 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0221X , with the licence number: 18975 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 108768500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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