Provider Demographics
NPI:1457331910
Name:WEISS, ELIZABETH T (M D)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:T
Last Name:WEISS
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 934
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-0934
Mailing Address - Country:US
Mailing Address - Phone:207-907-3339
Mailing Address - Fax:207-907-1214
Practice Address - Street 1:900 BROADWAY
Practice Address - Street 2:BLDG 3
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-1900
Practice Address - Country:US
Practice Address - Phone:207-907-3300
Practice Address - Fax:207-907-1923
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD11748207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME000210032Medicaid
MED03700Medicare UPIN
ME000210032Medicaid