Healthcare Provider Details

I. General information

NPI: 1871654384
Provider Name (Legal Business Name): MARK L WEISSMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4323 W RIVERSIDE DR
BURBANK CA
91505-4044
US

IV. Provider business mailing address

23388 MULHOLLAND DR
WOODLAND HILLS CA
91364-2733
US

V. Phone/Fax

Practice location:
  • Phone: 818-295-3379
  • Fax:
Mailing address:
  • Phone: 818-876-1636
  • Fax: 818-876-1516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberG55308
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: