Basic Information
| Provider Information | |||||||||
| NPI: | 1881855526 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEAVER | ||||||||
| FirstName: | OLUWATOYIN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 780 KUENZLI ST | ||||||||
| Address2: | STE 202 | ||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895020845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7759824590 | ||||||||
| FaxNumber: | 7759825496 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 E 2ND ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895021262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7759825003 | ||||||||
| FaxNumber: | 7759825103 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2008 | ||||||||
| LastUpdateDate: | 02/06/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 255426 | NY | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 14782 | NV | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 12278492 | 01 | CAQH | OTHER | 1881855526 | 05 | NV | MEDICAID |