Healthcare Provider Details

I. General information

NPI: 1871575217
Provider Name (Legal Business Name): GLEN H WEISS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2005
Last Update Date: 10/21/2020
Certification Date: 10/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 RAMAPO RD
GARNERVILLE NY
10923-1552
US

IV. Provider business mailing address

171 RAMAPO RD
GARNERVILLE NY
10923-1552
US

V. Phone/Fax

Practice location:
  • Phone: 845-947-2240
  • Fax: 845-947-2265
Mailing address:
  • Phone: 845-947-2240
  • Fax: 845-947-2265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number25MA07816400
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number192800
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: