Provider Demographics
NPI:1497986715
Name:WEITZ, JAN I (OD)
Entity Type:Individual
Prefix:DR
First Name:JAN
Middle Name:I
Last Name:WEITZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4820 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-1987
Mailing Address - Country:US
Mailing Address - Phone:718-439-7070
Mailing Address - Fax:718-439-0270
Practice Address - Street 1:4820 5TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-1987
Practice Address - Country:US
Practice Address - Phone:718-439-7070
Practice Address - Fax:718-439-0270
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-04
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007475152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA300060097Medicare PIN
NYG300060055Medicare PIN