Basic Information
| Provider Information | |||||||||
| NPI: | 1225004906 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEAVER | ||||||||
| FirstName: | CRAIG | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 847522 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752847522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035315000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2026 S JACKSON | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035865678 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2006 | ||||||||
| LastUpdateDate: | 10/14/2014 | ||||||||
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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 | H4782 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8A9565 | 01 | TX | BCBS | OTHER | 137834112 | 05 | TX | MEDICAID |