=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497211924
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN J. WEITER, MD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2019
-----------------------------------------------------
Last Update Date | 02/20/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 MILK STREET SUITE 202
-----------------------------------------------------
City | METHUEN
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01844-4662
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-854-5090
-----------------------------------------------------
Fax | 978-854-5755
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 39 CROSS ST SUITE 201
-----------------------------------------------------
City | PEABODY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01960
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-854-5090
-----------------------------------------------------
Fax | 978-854-5755
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | JOHN J. WEITER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 978-854-5090
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------