Provider Demographics
NPI:1003133299
Name:WEINER, SHOSHANA JO
Entity Type:Individual
Prefix:
First Name:SHOSHANA
Middle Name:JO
Last Name:WEINER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 64442
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4442
Mailing Address - Country:US
Mailing Address - Phone:667-214-1332
Mailing Address - Fax:410-328-8326
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:617-214-1332
Practice Address - Fax:410-328-8326
Is Sole Proprietor?:No
Enumeration Date:2010-04-27
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101253875207R00000X
DCMD041211207R00000X
MDD75548207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS062-0600OtherCAREFIRST BC/BS
MDS062-0600OtherCAREFIRST BC/BS