Healthcare Provider Details

I. General information

NPI: 1609404565
Provider Name (Legal Business Name): MITCHELL JOHN WEEMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2020
Last Update Date: 11/15/2023
Certification Date: 11/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 W COCOA BEACH CSWY
COCOA BEACH FL
32931-3585
US

IV. Provider business mailing address

1775 W HIBISCUS BLVD STE 215
MELBOURNE FL
32901-2627
US

V. Phone/Fax

Practice location:
  • Phone: 321-799-7111
  • Fax:
Mailing address:
  • Phone: 321-837-3825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number160791
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: