Provider Demographics
NPI:1881673606
Name:WESTON, WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:
Last Name:WESTON
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 1:1140 QUINCY AVE
Mailing Address - Street 2:
Mailing Address - City:DUNMORE
Mailing Address - State:PA
Mailing Address - Zip Code:18510-1150
Mailing Address - Country:US
Mailing Address - Phone:570-983-0360
Mailing Address - Fax:570-983-0375
Practice Address - Street 1:1140 QUINCY AVE
Practice Address - Street 2:
Practice Address - City:DUNMORE
Practice Address - State:PA
Practice Address - Zip Code:18510-1150
Practice Address - Country:US
Practice Address - Phone:570-983-0360
Practice Address - Fax:570-983-0375
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD037284E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001122760Medicaid
PA161669Medicare PIN
PA001122760Medicaid