Healthcare Provider Details

I. General information

NPI: 1396196101
Provider Name (Legal Business Name): MARTIN WEAVER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2016
Last Update Date: 08/31/2021
Certification Date: 08/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 N FEDERAL HWY STE 102
FORT LAUDERDALE FL
33308-3203
US

IV. Provider business mailing address

5400 N FEDERAL HWY STE 102
FORT LAUDERDALE FL
33308-3203
US

V. Phone/Fax

Practice location:
  • Phone: 954-866-9699
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number86393
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberME141148
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: