Basic Information
| Provider Information | |||||||||
| NPI: | 1780730366 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEAVER | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4600 HALE PKWY STE 340 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802204000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032800900 | ||||||||
| FaxNumber: | 3032803858 | ||||||||
| Practice Location | |||||||||
| Address1: | 4600 HALE PKWY STE 340 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802204000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032800900 | ||||||||
| FaxNumber: | 3032803858 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2007 | ||||||||
| LastUpdateDate: | 01/26/2022 | ||||||||
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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 | 208600000X | 062175 | GA | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 0048688 | CO | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 19726881 | 05 | CO | MEDICAID |