Provider Demographics
NPI:1154663623
Name:WEISS, MARK JASON (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JASON
Last Name:WEISS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 W DUNLAP AVE
Mailing Address - Street 2:STE 290
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-2737
Mailing Address - Country:US
Mailing Address - Phone:602-789-0344
Mailing Address - Fax:602-789-8389
Practice Address - Street 1:2510 W DUNLAP AVE
Practice Address - Street 2:STE 290
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-2737
Practice Address - Country:US
Practice Address - Phone:602-789-0344
Practice Address - Fax:602-789-8389
Is Sole Proprietor?:No
Enumeration Date:2013-03-22
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125062832208000000X
AZ006886208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics