Provider Demographics
NPI:1003801481
Name:WEISS, MARK JUSTIN (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JUSTIN
Last Name:WEISS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1717 S UTICA AVE
Mailing Address - Street 2:STE 107
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5317
Mailing Address - Country:US
Mailing Address - Phone:918-742-2428
Mailing Address - Fax:918-742-8435
Practice Address - Street 1:1717 S UTICA AVE
Practice Address - Street 2:STE 107
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5317
Practice Address - Country:US
Practice Address - Phone:918-742-2428
Practice Address - Fax:918-742-8435
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-13
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
OK9126207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D35392Medicare UPIN