Provider Demographics
NPI:1477634533
Name:WEINER, AVI (MD)
Entity Type:Individual
Prefix:
First Name:AVI
Middle Name:
Last Name:WEINER
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 1:47 OAK ST
Mailing Address - Street 2:STE 110
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-5320
Mailing Address - Country:US
Mailing Address - Phone:203-356-1450
Mailing Address - Fax:
Practice Address - Street 1:47 OAK ST
Practice Address - Street 2:STE 110
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-5320
Practice Address - Country:US
Practice Address - Phone:203-356-1450
Practice Address - Fax:203-323-8875
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT027452204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT027452OtherLICENSE
CTB37637Medicare UPIN
200000271Medicare ID - Type Unspecified