Provider Demographics
NPI:1992805626
Name:WEATHERDON, DEREK SCOTT (MD)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:SCOTT
Last Name:WEATHERDON
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 1:107 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28501-1603
Mailing Address - Country:US
Mailing Address - Phone:252-527-4146
Mailing Address - Fax:252-527-5697
Practice Address - Street 1:107 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28501-1603
Practice Address - Country:US
Practice Address - Phone:252-527-4146
Practice Address - Fax:252-527-5697
Is Sole Proprietor?:No
Enumeration Date:2006-09-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC01-28669OtherUNITED HEALTHCARE
NC89127WEMedicaid
NCA2087OtherMEDCOST
NC7736338OtherAETNA
NC127WEOtherBCBS/NC
NC01-28669OtherUNITED HEALTHCARE
NCG66708Medicare UPIN