Healthcare Provider Details

I. General information

NPI: 1992111884
Provider Name (Legal Business Name): MICAELA WEAVER D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2014
Last Update Date: 06/25/2021
Certification Date: 05/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BLACKSTONE STREET 2ND FLOOR
PROVIDENCE RI
02903
US

IV. Provider business mailing address

1 BLACKSTONE PL
PROVIDENCE RI
02903-4942
US

V. Phone/Fax

Practice location:
  • Phone: 401-453-7520
  • Fax:
Mailing address:
  • Phone: 401-453-7540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberDO00965
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number285738
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License NumberDO00965
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: