Healthcare Provider Details

I. General information

NPI: 1871760538
Provider Name (Legal Business Name): FREDERICK ETHAN WEISS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2008
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 W PLYMOUTH AVE
DELAND FL
32720-3236
US

IV. Provider business mailing address

960 MASSACHUSETTS AVE FLR 2
BOSTON MA
02118
US

V. Phone/Fax

Practice location:
  • Phone: 386-943-3160
  • Fax: 317-705-5047
Mailing address:
  • Phone: 617-414-5405
  • Fax: 617-414-6031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberME123132
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberME123132
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberME123132
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD448028
License Number StatePA
# 5
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberETL7045
License Number StateMA
# 6
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME155139
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: