MEDICARE: KENNETH WEISS M.D.

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	207Y00000X	Otolaryngology Physician	036053048	IL
2	207Y00000X	Otolaryngology Physician	ME103347	FL

General Provider Information

NPI Number	:	1538209515
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH WEISS M.D.

Provider Business Mailing Address
First Line	:	10377 S US HIGHWAY 1
Second Line	:	STE 101
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34952-5630
Country	:	US
Telephone Number	:	772-337-3700
Fax Number	:

Provider Business Practice Location Address
First Line	:	10377 S US HIGHWAY 1
Second Line	:	STE 101
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34952-5630
Country	:	US
Telephone Number	:	772-337-3700
Fax Number	:

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

Provider Enumeration Date	:	02/07/2007
Last Update Date	:	11/21/2012

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Directions to “ KENNETH WEISS M.D.” Practice Location

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