Provider Demographics
NPI:1093763245
Name:WEARY, DANITA RONIQUE (MD)
Entity Type:Individual
Prefix:DR
First Name:DANITA
Middle Name:RONIQUE
Last Name:WEARY
Suffix:
Gender:F
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 17918
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39122-7918
Mailing Address - Country:US
Mailing Address - Phone:601-442-5439
Mailing Address - Fax:601-442-3755
Practice Address - Street 1:136 JEFFERSON DAVIS BLVD
Practice Address - Street 2:
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120-5104
Practice Address - Country:US
Practice Address - Phone:601-442-5439
Practice Address - Fax:601-442-3755
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18242208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS2357393OtherUNITED HEALTHCARE
LA1166138Medicaid
MS05084709Medicaid
MS7513482OtherAETNA