Basic Information
Provider Information | |||||||||
NPI: | 1356603146 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WEAVER | ||||||||
FirstName: | LAUREN | ||||||||
MiddleName: | D'ANGELO | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | D'ANGELO | ||||||||
OtherFirstName: | LAUREN | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 14960 PARK ROW DR | ||||||||
Address2: |   | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770845165 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2812981144 | ||||||||
FaxNumber: | 2812981133 | ||||||||
Practice Location | |||||||||
Address1: | 920 MEDICAL PLAZA DR STE 120 | ||||||||
Address2: |   | ||||||||
City: | SHENANDOAH | ||||||||
State: | TX | ||||||||
PostalCode: | 773803275 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2812981144 | ||||||||
FaxNumber: | 2812981133 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/08/2012 | ||||||||
LastUpdateDate: | 08/30/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/30/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MT202213 | PA | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 2084E0001X | S3611 | TX | N |   |   |   |   | 2084N0402X | S3611 | TX | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology |
ID Information
ID | Type | State | Issuer | Description | 410428301 | 05 | TX |   | MEDICAID |