Provider Demographics
NPI:1417056417
Name:OLTI WEISSBRUN, VIVIAN (MD)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:
Last Name:OLTI WEISSBRUN
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 1:1680 MERIDIAN AVE STE 501
Mailing Address - Street 2:
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33139-2719
Mailing Address - Country:US
Mailing Address - Phone:305-531-5341
Mailing Address - Fax:305-532-5322
Practice Address - Street 1:1680 MERIDIAN AVE STE 501
Practice Address - Street 2:
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33139-2719
Practice Address - Country:US
Practice Address - Phone:305-531-5341
Practice Address - Fax:305-532-5322
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME417932084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL042281900Medicaid
FLME41793OtherLICENSE
FLME41793OtherLICENSE
FL042281900Medicaid
96928Medicare PIN
FLD64038Medicare UPIN