Provider Demographics
NPI:1760414312
Name:WEAVER, JOEY MATTHEW (OD)
Entity Type:Individual
Prefix:
First Name:JOEY
Middle Name:MATTHEW
Last Name:WEAVER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 GRAND CENTRAL AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:VIENNA
Mailing Address - State:WV
Mailing Address - Zip Code:26105-2147
Mailing Address - Country:US
Mailing Address - Phone:304-699-4540
Mailing Address - Fax:304-295-7822
Practice Address - Street 1:900 GRAND CENTRAL AVE
Practice Address - Street 2:SUITE C
Practice Address - City:VIENNA
Practice Address - State:WV
Practice Address - Zip Code:26105-2147
Practice Address - Country:US
Practice Address - Phone:304-699-4540
Practice Address - Fax:304-295-7822
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV883-OD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0149600000Medicaid
WV0149600000Medicaid
WVU09702Medicare UPIN
WV0679432Medicare ID - Type UnspecifiedWEST UNION
WV0679434Medicare ID - Type UnspecifiedPARKERSBURG
WVU09702Medicare UPIN