Provider Demographics
NPI:1447608096
Name:CHILDERS, WESTON
Entity Type:Individual
Prefix:
First Name:WESTON
Middle Name:
Last Name:CHILDERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 CHERRY ST BLDG A
Mailing Address - Street 2:SUITE 308
Mailing Address - City:BLUEFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:24701-3338
Mailing Address - Country:US
Mailing Address - Phone:304-325-1905
Mailing Address - Fax:304-324-2134
Practice Address - Street 1:122 12TH ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-2312
Practice Address - Country:US
Practice Address - Phone:304-487-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-24
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYC02676085207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine