Healthcare Provider Details

I. General information

NPI: 1104963958
Provider Name (Legal Business Name): JONATHAN RALPH WEISER M.D., P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3449 JOHNSON ST
HOLLYWOOD FL
33021-5420
US

IV. Provider business mailing address

3449 JOHNSON ST
HOLLYWOOD FL
33021-5420
US

V. Phone/Fax

Practice location:
  • Phone: 954-964-4113
  • Fax: 954-963-8121
Mailing address:
  • Phone: 954-964-4113
  • Fax: 954-963-8121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME62894
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: