Basic Information
| Provider Information | |||||||||
| NPI: | 1134161359 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEED | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1010 | ||||||||
| Address2: | |||||||||
| City: | ROCKDALE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765671010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124464500 | ||||||||
| FaxNumber: | 5124462063 | ||||||||
| Practice Location | |||||||||
| Address1: | 602 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ROCKDALE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765672323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124464555 | ||||||||
| FaxNumber: | 5124464533 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 02/08/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | D9716 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 136298005 | 05 | TX | MEDICAID | 50021402 | 01 | TX | DPS | OTHER | AW5655608 | 01 | TX | DEA | OTHER |