MEDICARE: JAY ELLIOT WEISSBLUTH M.D.

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	174400000X	Specialist	166454	NY

General Provider Information

NPI Number	:	1659376119
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAY ELLIOT WEISSBLUTH M.D.

Provider Business Mailing Address
First Line	:	3019 AVENUE U
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11229-5111
Country	:	US
Telephone Number	:	718-934-1800
Fax Number	:	718-891-5802

Provider Business Practice Location Address
First Line	:	3019 AVE U
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11229-5111
Country	:	US
Telephone Number	:	718-934-1800
Fax Number	:	718-891-5208

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

Provider Enumeration Date	:	06/20/2005
Last Update Date	:	07/08/2007

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