Healthcare Provider Details

I. General information

NPI: 1245332477
Provider Name (Legal Business Name): FREDERICK GORDON WEINSTEIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 07/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 WEST RD SUITE 102
TOWSON MD
21204-2316
US

IV. Provider business mailing address

110 WEST RD SUITE 102
TOWSON MD
21204-2316
US

V. Phone/Fax

Practice location:
  • Phone: 443-418-5999
  • Fax: 410-561-5598
Mailing address:
  • Phone: 443-418-5999
  • Fax: 410-561-5598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License NumberD29576
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberD29576
License Number StateMD

VII. Legacy identifiers

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

# 1
IdentifierE1630001
Identifier TypeOTHER
Identifier StateDC
Identifier IssuerBLUE CHOICE
# 2
Identifier523284
Identifier TypeOTHER
Identifier StateMD
Identifier IssuerAETNA HMO
# 3
Identifier8863
Identifier TypeOTHER
Identifier StateMD
Identifier IssuerBC/BS OF MARYLAND
# 4
IdentifierE163
Identifier TypeOTHER
Identifier StateMD
Identifier IssuerBC/NS OF DC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: