Healthcare Provider Details

I. General information

NPI: 1184616047
Provider Name (Legal Business Name): MARK J WEINER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 RIVER POINTE PKWY
CANTON GA
30114-2865
US

IV. Provider business mailing address

800 MOUNT VERNON HWY NE STE 120
ATLANTA GA
30328-4293
US

V. Phone/Fax

Practice location:
  • Phone: 770-720-4041
  • Fax: 770-479-4857
Mailing address:
  • Phone: 770-720-4041
  • Fax: 770-479-4857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number33748
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: