MEDICARE: DR. KENNETH A WEINBERG OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	749	TN
2	152WC0802X	Corneal and Contact Management Optometrist	749	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	103I411068	OTHER	TN	PTAN
2	103I411068	OTHER	TN	PTAN: 103I411068

General Provider Information

NPI Number	:	1740287853
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH A WEINBERG OD

Provider Business Mailing Address
First Line	:	826 MOUNT MORIAH RD
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38117-5705
Country	:	US
Telephone Number	:	901-683-3232
Fax Number	:

Provider Business Practice Location Address
First Line	:	826 MOUNT MORIAH RD
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38117-5705
Country	:	US
Telephone Number	:	901-683-3232
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/05/2005
Last Update Date	:	10/22/2014

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