=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225220346
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUSTIN EVERETT WEIGEL OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2007
-----------------------------------------------------
Last Update Date | 01/28/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11148 S LONE ELM RD
-----------------------------------------------------
City | OLATHE
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66061-9434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-390-6700
-----------------------------------------------------
Fax | 913-390-6705
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11148 S LONE ELM RD
-----------------------------------------------------
City | OLATHE
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66061-9434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-390-6700
-----------------------------------------------------
Fax | 913-390-6705
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1794
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152WC0802X
-----------------------------------------------------
Taxonomy Name | Corneal and Contact Management Optometrist
-----------------------------------------------------
License Number | 1794
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 152WP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Optometrist
-----------------------------------------------------
License Number | 1794
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------