Healthcare Provider Details

I. General information

NPI: 1528201472
Provider Name (Legal Business Name): PRABHA SWAMY WEISS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2009
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 MACK BAYOU LOOP STE 100
SANTA ROSA BEACH FL
32459
US

IV. Provider business mailing address

PO BOX 2699
PENSACOLA FL
32513-2699
US

V. Phone/Fax

Practice location:
  • Phone: 850-278-3136
  • Fax: 850-278-3104
Mailing address:
  • Phone: 850-475-4500
  • Fax: 850-475-4619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME133288
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number46187
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: