Healthcare Provider Details

I. General information

NPI: 1588693006
Provider Name (Legal Business Name): CARLA WEIS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 01/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 S MAIN ST PEDIATRIC SUBSPECIALTY FACULTY
ORANGE CA
92868-3835
US

IV. Provider business mailing address

9312 COMSTOCK DR
HUNTINGTON BEACH CA
92646-5926
US

V. Phone/Fax

Practice location:
  • Phone: 714-204-3096
  • Fax:
Mailing address:
  • Phone: 856-278-5591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberMD045476L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number25MA05602500
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number048399
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberG88609
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number13643
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: