Provider Demographics
NPI:1205949161
Name:WEINER, EDWARD L (OD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:L
Last Name:WEINER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1406 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526
Mailing Address - Country:US
Mailing Address - Phone:843-488-2020
Mailing Address - Fax:843-488-0141
Practice Address - Street 1:1406 MAIN STREET
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526
Practice Address - Country:US
Practice Address - Phone:843-488-2020
Practice Address - Fax:843-488-0141
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC915152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD09152Medicaid
U21450Medicare UPIN