Provider Demographics
NPI:1124026406
Name:WEITZMAN, HERVEY A (MD)
Entity Type:Individual
Prefix:
First Name:HERVEY
Middle Name:A
Last Name:WEITZMAN
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 1:175 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-1078
Mailing Address - Country:US
Mailing Address - Phone:203-365-6473
Mailing Address - Fax:203-396-1039
Practice Address - Street 1:175 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-1078
Practice Address - Country:US
Practice Address - Phone:203-365-6473
Practice Address - Fax:203-396-1039
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT24011207R00000X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001138940Medicaid
CT001138940Medicaid
B83601Medicare UPIN