Provider Demographics
NPI:1740287853
Name:WEINBERG, KENNETH A (OD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:A
Last Name:WEINBERG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:826 MOUNT MORIAH RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-5705
Mailing Address - Country:US
Mailing Address - Phone:901-683-3232
Mailing Address - Fax:
Practice Address - Street 1:826 MOUNT MORIAH RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117-5705
Practice Address - Country:US
Practice Address - Phone:901-683-3232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN749152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I411068OtherPTAN
TN103I411068OtherPTAN: 103I411068
TN103I411068OtherPTAN: 103I411068