MEDICARE: EDWARD WEAVER JR. O.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	152W00000X	Optometrist	1234	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
2	0250H	OTHER	NC	BCBS PROVIDER ID

General Provider Information

NPI Number	:	1346245263
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDWARD WEAVER JR. O.D.

Provider Business Mailing Address
First Line	:	1205 FLORAL PKWY
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28403-6216
Country	:	US
Telephone Number	:	910-791-6086
Fax Number	:

Provider Business Practice Location Address
First Line	:	1205 FLORAL PKWY
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28403-6216
Country	:	US
Telephone Number	:	910-791-6086
Fax Number	:	910-392-8087

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

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	08/20/2007

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