Provider Demographics
NPI:1417920836
Name:WEISER, MITCHELL M (MD)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:M
Last Name:WEISER
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 1:1200 EAST RIDGEWOOD AVENUE
Mailing Address - Street 2:2ND FLOOR E WING
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450
Mailing Address - Country:US
Mailing Address - Phone:201-670-8660
Mailing Address - Fax:201-447-1957
Practice Address - Street 1:1200 EAST RIDGEWOOD AVENUE
Practice Address - Street 2:2ND FLOOR E WING
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450
Practice Address - Country:US
Practice Address - Phone:201-670-8660
Practice Address - Fax:201-447-1957
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07585400207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ073591WC0Medicare PIN
H95073Medicare UPIN
NJ073591DCFMedicare PIN
762061Medicare ID - Type Unspecified