Provider Demographics
NPI:1417066374
Name:WEISS, MICHAEL CARL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CARL
Last Name:WEISS
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 1:3705 QUAIL COVEY DR
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-2278
Mailing Address - Country:US
Mailing Address - Phone:219-464-3941
Mailing Address - Fax:219-464-3941
Practice Address - Street 1:2401 VALLEY DR
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2520
Practice Address - Country:US
Practice Address - Phone:219-462-5195
Practice Address - Fax:219-462-5195
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01030965A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100208260AMedicaid
INCA0402OtherRAILROAD MEDICARE
IN000000090508OtherANTHEM BLUE CROSS BLUE SH
INCA0402OtherRAILROAD MEDICARE
IN658690AMedicare ID - Type Unspecified