Provider Demographics
NPI:1053304329
Name:WEINER, JEREMY PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:PAUL
Last Name:WEINER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 VELVET RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-3030
Mailing Address - Country:US
Mailing Address - Phone:410-323-9210
Mailing Address - Fax:410-323-9525
Practice Address - Street 1:5601 LOCH RAVEN BLVD
Practice Address - Street 2:POB #100
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21239-2905
Practice Address - Country:US
Practice Address - Phone:410-323-9210
Practice Address - Fax:410-323-9525
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0032984208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD9355006 00Medicaid
803QMedicare ID - Type Unspecified