Provider Demographics
NPI:1417090671
Name:WEISBERG, MARK M (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:M
Last Name:WEISBERG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2012 FITZWATER ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-1333
Mailing Address - Country:US
Mailing Address - Phone:702-338-2307
Mailing Address - Fax:267-319-1538
Practice Address - Street 1:2012 FITZWATER ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19146-1333
Practice Address - Country:US
Practice Address - Phone:702-338-2307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS-003767L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
01WCHFK02Medicare ID - Type Unspecified
C28612Medicare UPIN
NVBL404ZMedicare UPIN
NVBL404YMedicare UPIN
NVBK083AMedicare PIN
NVBK083BMedicare PIN