Healthcare Provider Details

I. General information

NPI: 1912910019
Provider Name (Legal Business Name): RONALD S WEISS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 04/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 HARLEM AVE
STICKNEY IL
60402-4250
US

IV. Provider business mailing address

4401 HARLEM AVE
STICKNEY IL
60402-4250
US

V. Phone/Fax

Practice location:
  • Phone: 708-788-3400
  • Fax:
Mailing address:
  • Phone: 708-788-3400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036079050
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: