Healthcare Provider Details

I. General information

NPI: 1568466258
Provider Name (Legal Business Name): JEFFREY L WEINGARTEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 09/22/2020
Certification Date: 09/22/2020
Deactivation Date: 03/15/2006
Reactivation Date: 03/22/2006

III. Provider practice location address

2799 W GRAND BLVD
DETROIT MI
48202-2608
US

IV. Provider business mailing address

1135 W UNIVERSITY DR STE 210
ROCHESTER HILLS MI
48307-1872
US

V. Phone/Fax

Practice location:
  • Phone: 800-653-6568
  • Fax:
Mailing address:
  • Phone: 248-650-4660
  • Fax: 248-650-4663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number4301402858
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberJW402858
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: