Healthcare Provider Details

I. General information

NPI: 1366505513
Provider Name (Legal Business Name): BRUCE ALAN WEISS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7425 N BEACH CT
FOX POINT WI
53217-3656
US

IV. Provider business mailing address

7425 N BEACH CT
FOX POINT WI
53217-3656
US

V. Phone/Fax

Practice location:
  • Phone: 414-540-2251
  • Fax: 414-540-2144
Mailing address:
  • Phone: 414-540-2251
  • Fax: 414-540-2144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number49652-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: