Provider Demographics
NPI:1225087877
Name:WEISS, KENNETH (DO)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:WEISS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8101 WASHINGTON LN
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WYNCOTE
Mailing Address - State:PA
Mailing Address - Zip Code:19095-1625
Mailing Address - Country:US
Mailing Address - Phone:215-886-0440
Mailing Address - Fax:215-886-0447
Practice Address - Street 1:8101 WASHINGTON LN
Practice Address - Street 2:SUITE 101
Practice Address - City:WYNCOTE
Practice Address - State:PA
Practice Address - Zip Code:19095-1625
Practice Address - Country:US
Practice Address - Phone:215-886-0440
Practice Address - Fax:215-886-0447
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAOS006790E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA620900Medicare PIN