Provider Demographics
NPI:1245342765
Name:WEIDMAN, PAUL DANIEL (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:DANIEL
Last Name:WEIDMAN
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 623
Mailing Address - Street 2:
Mailing Address - City:SOUTH HILL
Mailing Address - State:VA
Mailing Address - Zip Code:23970-0623
Mailing Address - Country:US
Mailing Address - Phone:434-584-0046
Mailing Address - Fax:434-584-0083
Practice Address - Street 1:420 DURANT ST
Practice Address - Street 2:
Practice Address - City:SOUTH HILL
Practice Address - State:VA
Practice Address - Zip Code:23970-1614
Practice Address - Country:US
Practice Address - Phone:434-584-0046
Practice Address - Fax:434-584-0083
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21733207Q00000X
OH3584922207Q00000X
VA0101261879207QA0401X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810001239Medicaid
OH2513917Medicaid
WV001712686OtherMS BLUE CROSS BLUE SHIELD
P00220382OtherRAILROAD MEDICARE
I22787Medicare UPIN
OH4148361Medicare PIN
P00220382OtherRAILROAD MEDICARE