Provider Demographics
NPI:1003033648
Name:WEINER, PHYLLIS DUNN (MD)
Entity Type:Individual
Prefix:DR
First Name:PHYLLIS
Middle Name:DUNN
Last Name:WEINER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20011 KENO AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLIS
Mailing Address - State:NY
Mailing Address - Zip Code:11423-1435
Mailing Address - Country:US
Mailing Address - Phone:718-465-8792
Mailing Address - Fax:718-776-2368
Practice Address - Street 1:20011 KENO AVE
Practice Address - Street 2:
Practice Address - City:HOLLIS
Practice Address - State:NY
Practice Address - Zip Code:11423-1435
Practice Address - Country:US
Practice Address - Phone:718-465-8792
Practice Address - Fax:718-776-2368
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY092864208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00977615Medicaid
NYF29927Medicare UPIN
NY00977615Medicaid