Basic Information
| Provider Information | |||||||||
| NPI: | 1215902721 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEIL | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WEIL, P.C. | ||||||||
| OtherFirstName: | J | ||||||||
| OtherMiddleName: | MICHAEL | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | O.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4554 VIRGINIA BEACH BLVD | ||||||||
| Address2: | STE 660 | ||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234623045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574971724 | ||||||||
| FaxNumber: | 7574992227 | ||||||||
| Practice Location | |||||||||
| Address1: | 549 E. BRAMBLETON AVE | ||||||||
| Address2: | JENCARE NEIGHBORHOOD MEDICAL NORFOLK, LLC | ||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7575339441 | ||||||||
| FaxNumber: | 7574461454 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2006 | ||||||||
| LastUpdateDate: | 03/11/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 0618000283 | VA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 9235311 | 05 | VA | MEDICAID |