Provider Demographics
NPI:1083721591
Name:KERIN WEISSERMAN, DOLLY (MD)
Entity Type:Individual
Prefix:DR
First Name:DOLLY
Middle Name:
Last Name:KERIN WEISSERMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DOLLY
Other - Middle Name:
Other - Last Name:KERIN WEISSERMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1811 WILSHIRE BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-5626
Mailing Address - Country:US
Mailing Address - Phone:310-453-9010
Mailing Address - Fax:310-828-3661
Practice Address - Street 1:16547 PARK LANE CIR
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-1184
Practice Address - Country:US
Practice Address - Phone:248-980-3655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC56036208000000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0000Medicare UPIN