Provider Demographics
NPI:1073528386
Name:WEAVER, TOMMY L (MD)
Entity Type:Individual
Prefix:
First Name:TOMMY
Middle Name:L
Last Name:WEAVER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 221249
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28222-1249
Mailing Address - Country:US
Mailing Address - Phone:704-332-1291
Mailing Address - Fax:700-926-1832
Practice Address - Street 1:3623 LATROBE DR STE 216
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-2117
Practice Address - Country:US
Practice Address - Phone:704-332-1291
Practice Address - Fax:704-926-1832
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2020-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCME110442085U0001X, 2085B0100X, 2085N0904X, 2085P0229X, 2085R0202X, 2085R0204X
NC93007692085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC110445Medicaid
NC89063U2Medicaid
SC2001OtherMEDICARE GROUP
NC89063U2Medicaid
SC110445Medicaid
300110729Medicare ID - Type UnspecifiedRR