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Individual

BLAKE WEAVER

Active
Sole proprietor
No

Provider details

NPI number
Gender
Man
Credential
D.O.

Contact information

Practice address
902 S BRYANT AVE, EDMOND, OK 73034-5742
(405) 348-1900
(405) 348-0423
Mailing address
902 S BRYANT AVE, EDMOND, OK 73034-5742
(405) 348-1900
(405) 348-0423

Taxonomy

Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
4267
OK
2085R0202X
Diagnostic Radiology Physician
Primary
4267
OK

Other

Other identifiers
Code
Description
Identifier
Issuer
State
05
200058090A
OK
Enumeration date
07/03/2006
Last updated
08/18/2015
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