Provider Demographics
NPI:1104826585
Name:WEINGARTEN, CLIFFORD
Entity Type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:
Last Name:WEINGARTEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 LEEFIELD GATE
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-1612
Mailing Address - Country:US
Mailing Address - Phone:631-427-7651
Mailing Address - Fax:631-549-1526
Practice Address - Street 1:2 LEEFIELD GATE
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-1612
Practice Address - Country:US
Practice Address - Phone:631-427-7651
Practice Address - Fax:631-549-1526
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-27
Last Update Date:2010-09-29
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
NY083595207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00623318Medicaid
NYD38049Medicare UPIN
NY263221Medicare ID - Type Unspecified