Provider Demographics
NPI:1396763439
Name:WEINER, EVAN (MD)
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:WEINER
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 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6812
Mailing Address - Fax:570-271-6507
Practice Address - Street 1:100 N ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17822-4903
Practice Address - Country:US
Practice Address - Phone:570-271-6812
Practice Address - Fax:570-271-6507
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2025-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4314282080P0204X, 2080P0204X
NJ25MA09584800208000000X, 2080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2711630-00Medicaid
FLI23709Medicare UPIN
FL52073AMedicare ID - Type Unspecified