Healthcare Provider Details

I. General information

NPI: 1760559496
Provider Name (Legal Business Name): GARRY DEAN WEIDE JR. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 10TH ST SE
CEDAR RAPIDS IA
52403-2414
US

IV. Provider business mailing address

202 10TH ST SE
CEDAR RAPIDS IA
52403-2414
US

V. Phone/Fax

Practice location:
  • Phone: 319-362-5118
  • Fax: 319-364-0574
Mailing address:
  • Phone: 319-362-5118
  • Fax: 319-364-0574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number036134829
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: