Healthcare Provider Details

I. General information

NPI: 1609141233
Provider Name (Legal Business Name): KYLE JONATHAN WEAVER OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2012
Last Update Date: 08/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2740 NAVARRE AVE
OREGON OH
43616
US

IV. Provider business mailing address

4100 W 3RD ST
DAYTON OH
45428-9000
US

V. Phone/Fax

Practice location:
  • Phone: 419-693-4444
  • Fax: 419-697-2149
Mailing address:
  • Phone: 260-729-2311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18003711A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: