Healthcare Provider Details

I. General information

NPI: 1588608509
Provider Name (Legal Business Name): ROBERT MICHAEL WEAVER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 08/27/2020
Certification Date: 08/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1146 EVELYN GANDY PKWY
PETAL MS
39465
US

IV. Provider business mailing address

1146 EVELYN GANDY PKWY
PETAL MS
39465-3947
US

V. Phone/Fax

Practice location:
  • Phone: 601-584-4309
  • Fax: 601-584-4890
Mailing address:
  • Phone: 601-584-4309
  • Fax: 601-584-4890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number12277
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: