Provider Demographics
NPI:1174650279
Name:MARC W. WEISE, M.D., INC.
Entity Type:Organization
Organization Name:MARC W. WEISE, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:W
Authorized Official - Last Name:WEISE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-773-2650
Mailing Address - Street 1:2 JAMES WAY
Mailing Address - Street 2:SUITE 115
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-4973
Mailing Address - Country:US
Mailing Address - Phone:805-773-2650
Mailing Address - Fax:805-773-2655
Practice Address - Street 1:2 JAMES WAY
Practice Address - Street 2:SUITE 115
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-4973
Practice Address - Country:US
Practice Address - Phone:805-773-2650
Practice Address - Fax:805-773-2655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2852009207X00000X
CA5684480001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
611373100OtherUSDEPT OF LABOR
CA5684480001Medicare NSC
W19751Medicare PIN
DE8913Medicare PIN