Provider Demographics
NPI:1386936839
Name:WAXWEILER, WESTON THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:WESTON
Middle Name:THOMAS
Last Name:WAXWEILER
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 1:59 TIPTON DR
Mailing Address - Street 2:
Mailing Address - City:DAHLONEGA
Mailing Address - State:GA
Mailing Address - Zip Code:30533-1603
Mailing Address - Country:US
Mailing Address - Phone:770-800-3455
Mailing Address - Fax:770-450-8024
Practice Address - Street 1:105 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-2381
Practice Address - Country:US
Practice Address - Phone:770-800-3455
Practice Address - Fax:770-284-8380
Is Sole Proprietor?:No
Enumeration Date:2011-05-03
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA073880207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003166483CMedicaid
GA003166483DMedicaid
GA03277940OtherAMERIGROUP
GA003166483AMedicaid
GA003166483BMedicaid
GA003166483FMedicaid