Provider Demographics
NPI:1265652317
Name:WEAVER, KEITH ANDREW (DO)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:ANDREW
Last Name:WEAVER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1013 EXECUTIVE DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-7912
Mailing Address - Country:US
Mailing Address - Phone:423-875-2538
Mailing Address - Fax:423-875-2539
Practice Address - Street 1:1013 EXECUTIVE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-7912
Practice Address - Country:US
Practice Address - Phone:423-875-2538
Practice Address - Fax:423-875-2539
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-30
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102201853202C00000X
TN2076208D00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No202C00000XAllopathic & Osteopathic PhysiciansIndependent Medical Examiner
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1519501Medicaid