MEDICARE: MARK JUSTIN WEISS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	9126	OK

General Provider Information

NPI Number	:	1003801481
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK JUSTIN WEISS MD

Provider Business Mailing Address
First Line	:	1717 S UTICA AVE
Second Line	:	STE 107
City	:	TULSA
State	:	OK
Zip	:	74104-5317
Country	:	US
Telephone Number	:	918-742-2428
Fax Number	:	918-742-8435

Provider Business Practice Location Address
First Line	:	1717 S UTICA AVE
Second Line	:	STE 107
City	:	TULSA
State	:	OK
Zip	:	74104-5317
Country	:	US
Telephone Number	:	918-742-2428
Fax Number	:	918-742-8435

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/13/2005
Last Update Date	:	07/08/2007

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