Healthcare Provider Details

I. General information

NPI: 1730133448
Provider Name (Legal Business Name): RONALD WEINER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 01/08/2024
Certification Date: 01/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 CENTRE PLAZA DR
JACKSON TN
38305-2862
US

IV. Provider business mailing address

17 CENTRE PLAZA DR
JACKSON TN
38305-2862
US

V. Phone/Fax

Practice location:
  • Phone: 731-512-0104
  • Fax: 731-668-7388
Mailing address:
  • Phone: 731-512-0104
  • Fax: 731-668-7388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number1124
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberDO1124
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: