Provider Demographics
NPI:1316914500
Name:WEATHERINGTON, MARY
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:WEATHERINGTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5428 POLO WOODS CT
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-4778
Mailing Address - Country:US
Mailing Address - Phone:513-829-9731
Mailing Address - Fax:
Practice Address - Street 1:1401 STEFFEN AVE
Practice Address - Street 2:
Practice Address - City:LINCOLN HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:45215-2338
Practice Address - Country:US
Practice Address - Phone:513-588-3623
Practice Address - Fax:513-588-3649
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-06-6966-W207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0160089Medicaid
OH0160089Medicaid