Provider Demographics
NPI:1346251469
Name:WEAVER, EDGAR N JR (MD)
Entity Type:Individual
Prefix:DR
First Name:EDGAR
Middle Name:N
Last Name:WEAVER
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1234 FRANKLIN RD SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24016-4606
Mailing Address - Country:US
Mailing Address - Phone:540-772-7107
Mailing Address - Fax:540-772-7858
Practice Address - Street 1:5304 INDIAN GRAVE RD SW
Practice Address - Street 2:SUITE A
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-9108
Practice Address - Country:US
Practice Address - Phone:540-772-7107
Practice Address - Fax:540-772-7858
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101033189207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006196705Medicaid
C12923OtherRAILROAD MEDICARE LEGACY
140001855OtherRAILROAD MEDICARE
VAC01334OtherMEDICARE LEGACY GROUP NUM
B07189Medicare UPIN
VA006196705Medicaid