Healthcare Provider Details

I. General information

NPI: 1003922618
Provider Name (Legal Business Name): GARY M. WEISS, M.D., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 09/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1051 PORT MALABAR BLVD NE SUITE 6
PALM BAY FL
32905-5153
US

IV. Provider business mailing address

1051 PORT MALABAR BLVD NE SUITE 6
PALM BAY FL
32905-5153
US

V. Phone/Fax

Practice location:
  • Phone: 321-727-9063
  • Fax: 321-728-1955
Mailing address:
  • Phone: 321-727-9063
  • Fax: 321-728-1955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME 62341
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number9168017
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2100062
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME 39943
License Number StateFL

VIII. Authorized Official

Name: DR. GARY M WEISS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 321-727-9063