Provider Demographics
NPI:1114910320
Name:WEICKER, CRISTIN A (DO)
Entity Type:Individual
Prefix:DR
First Name:CRISTIN
Middle Name:A
Last Name:WEICKER
Suffix:
Gender:F
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:PO BOX 783311
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-3311
Mailing Address - Country:US
Mailing Address - Phone:484-884-4500
Mailing Address - Fax:
Practice Address - Street 1:205 E LAUREL BLVD
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-2534
Practice Address - Country:US
Practice Address - Phone:570-622-1887
Practice Address - Fax:570-622-1959
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2017-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS013220207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1013949780001Medicaid
PAP00232917OtherRAILROAD MEDICARE
PAP00232917OtherRAILROAD MEDICARE
PAI35256Medicare UPIN