MEDICARE: JOHN C WEAVER MD A PROFESSIONAL CORPORATION

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	208D00000X	General Practice Physician	G35959	CA

General Provider Information

NPI Number	:	1366577744
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHN C WEAVER MD A PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	PO BOX 424
Second Line	:
City	:	CULVER CITY
State	:	CA
Zip	:	90232-0424
Country	:	US
Telephone Number	:	323-724-8164
Fax Number	:	323-724-9207

Provider Business Practice Location Address
First Line	:	204 S ATLANTIC BLVD
Second Line	:	SUITE 2
City	:	LOS ANGELES
State	:	CA
Zip	:	90022-1755
Country	:	US
Telephone Number	:	323-724-8164
Fax Number	:	323-724-9207

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JOHN C WEAVER
Credential	:	M.D.
Telephone Number	:	323-724-8164

Provider Enumeration Date	:	02/23/2007
Last Update Date	:	08/22/2020

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