Provider Demographics
NPI:1497783161
Name:WEISS, KENNETH L (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:L
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 1:1400 NW 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-1003
Mailing Address - Country:US
Mailing Address - Phone:305-243-5512
Mailing Address - Fax:305-243-4613
Practice Address - Street 1:1400 NW 12TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1003
Practice Address - Country:US
Practice Address - Phone:305-243-5512
Practice Address - Fax:305-243-4613
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-05-22642085R0202X
FLME869862085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2032017Medicaid
MSP01212498OtherRAILROAD MEDICARE
OH2591054OtherAETNA
KY64037559Medicaid
WV3810002515Medicaid
OH000000199157OtherANTHEM
IN200343060Medicaid
OHWE4055132Medicare PIN
MSP01212498OtherRAILROAD MEDICARE