Provider Demographics
NPI:1013052596
Name:WEAVER, CARRIE (OD)
Entity Type:Individual
Prefix:DR
First Name:CARRIE
Middle Name:
Last Name:WEAVER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2630 PETERS CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127-5655
Mailing Address - Country:US
Mailing Address - Phone:336-785-3486
Mailing Address - Fax:336-785-3002
Practice Address - Street 1:2741 OLD HOLLOW RD
Practice Address - Street 2:
Practice Address - City:WALKERTOWN
Practice Address - State:NC
Practice Address - Zip Code:27051-9529
Practice Address - Country:US
Practice Address - Phone:336-595-4588
Practice Address - Fax:336-595-6277
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1593152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0996BOtherBLUECROSS
NC890996BMedicaid
NC890996BMedicaid
NC2469803Medicare ID - Type Unspecified