Provider Demographics
NPI:1871684316
Name:WEAVER, COREENA L (MD)
Entity Type:Individual
Prefix:
First Name:COREENA
Middle Name:L
Last Name:WEAVER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 NORTH WAY
Mailing Address - Street 2:
Mailing Address - City:CAMILLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13031-1498
Mailing Address - Country:US
Mailing Address - Phone:315-487-1541
Mailing Address - Fax:315-487-3485
Practice Address - Street 1:601 NORTH WAY
Practice Address - Street 2:
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031-1498
Practice Address - Country:US
Practice Address - Phone:315-487-1541
Practice Address - Fax:315-487-3485
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1808391208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01243654Medicaid