Healthcare Provider Details

I. General information

NPI: 1154663623
Provider Name (Legal Business Name): MARK JASON WEISS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2013
Last Update Date: 09/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 W DUNLAP AVE STE 290
PHOENIX AZ
85021-2737
US

IV. Provider business mailing address

2510 W DUNLAP AVE STE 290
PHOENIX AZ
85021-2737
US

V. Phone/Fax

Practice location:
  • Phone: 602-789-0344
  • Fax: 602-789-8389
Mailing address:
  • Phone: 602-789-0344
  • Fax: 602-789-8389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125062832
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number006886
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: