Provider Demographics
NPI:1942262167
Name:WEAVER, KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
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:PO BOX 67
Mailing Address - Street 2:
Mailing Address - City:JONESBOROUGH
Mailing Address - State:TN
Mailing Address - Zip Code:37659
Mailing Address - Country:US
Mailing Address - Phone:423-753-4177
Mailing Address - Fax:423-753-8030
Practice Address - Street 1:1103 E JACKSON BLVD
Practice Address - Street 2:STE 1
Practice Address - City:JONESBOROUGH
Practice Address - State:TN
Practice Address - Zip Code:37659
Practice Address - Country:US
Practice Address - Phone:423-753-4177
Practice Address - Fax:423-753-8030
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD11216207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3166800Medicaid
B03198Medicare UPIN
TN3166800Medicare ID - Type Unspecified