=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245342765
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAUL DANIEL WEIDMAN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2006
-----------------------------------------------------
Last Update Date | 03/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 420 DURANT ST
-----------------------------------------------------
City | SOUTH HILL
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23970-1614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-584-0046
-----------------------------------------------------
Fax | 434-584-0083
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 623
-----------------------------------------------------
City | SOUTH HILL
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23970-0623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-584-0046
-----------------------------------------------------
Fax | 434-584-0083
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 21733
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 3584922
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207QA0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 0101261879
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 0101261879
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------