Provider Demographics
NPI:1376632158
Name:WEISS, JUDITH H (MD)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:H
Last Name:WEISS
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 1:7350 INDUSTRIAL PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-5318
Mailing Address - Country:US
Mailing Address - Phone:216-732-9480
Mailing Address - Fax:
Practice Address - Street 1:6701 ROCKSIDE RD
Practice Address - Street 2:SUITE 260
Practice Address - City:INDEPENDENCE
Practice Address - State:OH
Practice Address - Zip Code:44131-2358
Practice Address - Country:US
Practice Address - Phone:216-369-2525
Practice Address - Fax:216-369-2531
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV16545207Q00000X
CAG68883207Q00000X
WY10681A207Q00000X
WAMD60633801207Q00000X
AZ52042207Q00000X
MTMED-PHYS-LIC-44990207Q00000X
IDM-13196207Q00000X
CODR.0057080207Q00000X
ORMD175712207Q00000X
NMMD2016-0808207Q00000X
AK114311207Q00000X
HIMD-18905207Q00000X
OH35052437207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0944607Medicaid
OH000000533747OtherANTHEM
OH408442OtherWELLCARE
OH9006404OtherSUMMACARE
OH0750897Medicare PIN
F12085Medicare UPIN
OH0944607Medicaid
OHP00462702Medicare PIN
OH9006404OtherSUMMACARE