Healthcare Provider Details

I. General information

NPI: 1760456396
Provider Name (Legal Business Name): WAYNE MARK WEISS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 02/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

384 CRYSTAL RUN RD SUITE 201
MIDDLETOWN NY
10941-4013
US

IV. Provider business mailing address

384 CRYSTAL RUN RD SUITE 201
MIDDLETOWN NY
10941-4013
US

V. Phone/Fax

Practice location:
  • Phone: 845-692-8780
  • Fax: 845-692-3439
Mailing address:
  • Phone: 845-692-8780
  • Fax: 845-692-3439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number170579
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number170579
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: