Provider Demographics
NPI:1033209804
Name:WEISSMAN, EVAN (DO)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:WEISSMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 MEDICAL PARK DR
Mailing Address - Street 2:4C
Mailing Address - City:POMONA
Mailing Address - State:NY
Mailing Address - Zip Code:10970-3516
Mailing Address - Country:US
Mailing Address - Phone:845-362-0202
Mailing Address - Fax:845-362-1347
Practice Address - Street 1:4 MEDICAL PARK DR
Practice Address - Street 2:4C
Practice Address - City:POMONA
Practice Address - State:NY
Practice Address - Zip Code:10970-3516
Practice Address - Country:US
Practice Address - Phone:845-362-0202
Practice Address - Fax:845-362-1347
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NYBW6237653208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2089054Medicaid
NY2089054Medicaid