Provider Demographics
NPI:1003922618
Name:GARY M. WEISS, M.D., P.A.
Entity Type:Organization
Organization Name:GARY M. WEISS, M.D., P.A.
Other - Org Name:WEISS & NEWBERRY MEDICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:WEISS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-727-9063
Mailing Address - Street 1:1051 PORT MALABAR BLVD NE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-5153
Mailing Address - Country:US
Mailing Address - Phone:321-727-9063
Mailing Address - Fax:321-728-1955
Practice Address - Street 1:1051 PORT MALABAR BLVD NE
Practice Address - Street 2:SUITE 6
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-5153
Practice Address - Country:US
Practice Address - Phone:321-727-9063
Practice Address - Fax:321-728-1955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 39943174400000X
FLME 62341174400000X
FL9168017363L00000X
FL2100062363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL62367OtherBLUE CROSS BLUE SHIELD
FL066754400Medicaid
FLD65340Medicare UPIN
FL066754400Medicaid