Provider Demographics
NPI:1689671430
Name:WEAVER, KENNETH RAY (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:RAY
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 1:715 SHAKER DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-3674
Mailing Address - Country:US
Mailing Address - Phone:859-313-5000
Mailing Address - Fax:859-313-5002
Practice Address - Street 1:715 SHAKER DR STE 110
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3674
Practice Address - Country:US
Practice Address - Phone:859-313-5000
Practice Address - Fax:859-313-5002
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2017-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY23010207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64230105Medicaid
KY611164546OtherUNITED HEALTHCARE
KY000000068949OtherBLUE CROSS BLUE SHIELD
KY000000073116OtherBLUE CROSS
KY64230105Medicaid
KY000000073116OtherBLUE CROSS
KY000000068949OtherBLUE CROSS BLUE SHIELD