Provider Demographics
NPI:1164428611
Name:WEINE, GARY ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:ROBERT
Last Name:WEINE
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 1:95 MADISON AVE
Mailing Address - Street 2:STE 405
Mailing Address - City:MORRISTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07960-7336
Mailing Address - Country:US
Mailing Address - Phone:973-829-9998
Mailing Address - Fax:
Practice Address - Street 1:95 MADISON AVE
Practice Address - Street 2:SUITE 405
Practice Address - City:MORRISTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07960-6092
Practice Address - Country:US
Practice Address - Phone:973-829-9998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03540500207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0675300Medicaid
NJE22036Medicare UPIN
NJ463410BMHMedicare ID - Type Unspecified