MEDICARE: JOHN ROUSE WEATHERS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	2012-00190	NC
2	207R00000X	Internal Medicine Physician	2012-00190	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1215198155
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN ROUSE WEATHERS M.D.

Provider Business Mailing Address
First Line	:	PO BOX 751803
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28275-1803
Country	:	US
Telephone Number	:	336-766-0547
Fax Number	:	336-766-0549

Provider Business Practice Location Address
First Line	:	105 STADIUM OAKS DR
Second Line	:
City	:	CLEMMONS
State	:	NC
Zip	:	27012-8962
Country	:	US
Telephone Number	:	336-766-0547
Fax Number	:	336-766-0549

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2008
Last Update Date	:	10/28/2020

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Directions to “ JOHN ROUSE WEATHERS M.D.” Practice Location

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