Healthcare Provider Details

I. General information

NPI: 1164657375
Provider Name (Legal Business Name): CRYSTAL WEIS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2009
Last Update Date: 02/04/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24800 SE STARK ST
GRESHAM OR
97030-3378
US

IV. Provider business mailing address

3311 HARVEY ST APT E
MADISON WI
53705-3456
US

V. Phone/Fax

Practice location:
  • Phone: 503-674-1122
  • Fax:
Mailing address:
  • Phone: 608-215-5168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD60617983
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number155139
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: