Provider Demographics
NPI:1164657375
Name:WEIS, CRYSTAL (MD)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:WEIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3311 HARVEY ST
Mailing Address - Street 2:APT E
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-3456
Mailing Address - Country:US
Mailing Address - Phone:608-215-5168
Mailing Address - Fax:
Practice Address - Street 1:24800 SE STARK ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3378
Practice Address - Country:US
Practice Address - Phone:503-674-1122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-18
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60617983207P00000X
OR155139207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine