=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386638997
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CURTIS WEAVER O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2005
-----------------------------------------------------
Last Update Date | 02/26/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 160 DANADA SQ W
-----------------------------------------------------
City | WHEATON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60189-2041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-752-0595
-----------------------------------------------------
Fax | 630-752-0145
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 241 W 17TH ST
-----------------------------------------------------
City | LOMBARD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60148-6138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-916-7992
-----------------------------------------------------
Fax | 630-752-0145
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 046-007064
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------