=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497977334
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AVI WEISS M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2007
-----------------------------------------------------
Last Update Date | 11/25/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3150N TENAYA WAY 165
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89128-0462
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-877-0814
-----------------------------------------------------
Fax | 702-877-3238
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 35380
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89133-5380
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-877-0814
-----------------------------------------------------
Fax | 702-887-3238
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number | 125-050007
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number | 13116
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------