Healthcare Provider Details

I. General information

NPI: 1417989344
Provider Name (Legal Business Name): FRED A. WEAVER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 11/27/2023
Certification Date: 10/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 SAN PABLO ST SUITE 4300
LOS ANGELES CA
90033-5330
US

IV. Provider business mailing address

PO BOX 31309
LOS ANGELES CA
90031-0309
US

V. Phone/Fax

Practice location:
  • Phone: 323-442-5849
  • Fax:
Mailing address:
  • Phone: 323-442-5849
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberG57487
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: