Provider Demographics
NPI:1336120906
Name:WEISBERG, MITCHELL B (MD)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:B
Last Name:WEISBERG
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 1:1500 BEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-5646
Mailing Address - Country:US
Mailing Address - Phone:386-213-4148
Mailing Address - Fax:386-213-4153
Practice Address - Street 1:1500 BEVILLE RD STE 105
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-5644
Practice Address - Country:US
Practice Address - Phone:386-213-4148
Practice Address - Fax:386-213-4153
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME63365207R00000X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10612327OtherCIGNA
FL375700500OtherMEDICAID SECONDARY
FL650879131OtherUNITED HEALTH CARE
FL650879131OtherCHOICE CARE
FL18673OtherBC/BS OF FL
FL5767330OtherAETNA