Provider Demographics
NPI:1386692770
Name:WEAVER, RUSTY JOE (OD)
Entity type:Individual
Prefix:DR
First Name:RUSTY
Middle Name:JOE
Last Name:WEAVER
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 1:1600 GRAND CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:WV
Mailing Address - Zip Code:26105-1059
Mailing Address - Country:US
Mailing Address - Phone:304-295-8561
Mailing Address - Fax:304-295-9164
Practice Address - Street 1:1600 GRAND CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:WV
Practice Address - Zip Code:26105-1059
Practice Address - Country:US
Practice Address - Phone:304-295-8561
Practice Address - Fax:304-295-9164
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV821 OD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0149294000Medicaid
WV0149294000Medicaid
WVWE0678352Medicare ID - Type Unspecified