Provider Demographics
NPI:1336113604
Name:WEISE, ERIK S (MD)
Entity Type:Individual
Prefix:
First Name:ERIK
Middle Name:S
Last Name:WEISE
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 1:6680 POE AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45414-2855
Mailing Address - Country:US
Mailing Address - Phone:937-280-8400
Mailing Address - Fax:937-280-8373
Practice Address - Street 1:2350 MIAMI VALLEY DR STE 500
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-4780
Practice Address - Country:US
Practice Address - Phone:937-293-1622
Practice Address - Fax:937-245-6308
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-096132208800000X
IN01061364A208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2683323Medicaid
IN100081380Medicaid
IN200531020Medicaid
OH0748972Medicaid
IN136140UMedicare PIN
IN100081380Medicaid
IN136140Medicare PIN
OH9928923Medicare PIN
INH87760Medicare UPIN
OH0748972Medicaid
IN0335410013Medicare NSC
OH4309321Medicare PIN
IN150640OOOMedicare PIN
INCB9217Medicare PIN