Provider Demographics
NPI:1508820242
Name:WEINGARTEN, ELIZABETH ANN (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:WEINGARTEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:ANN
Other - Last Name:GRUCELLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:112 OLEAN ST
Mailing Address - Street 2:SUITE 220
Mailing Address - City:EAST AURORA
Mailing Address - State:NY
Mailing Address - Zip Code:14052-2540
Mailing Address - Country:US
Mailing Address - Phone:716-805-1072
Mailing Address - Fax:716-805-1073
Practice Address - Street 1:112 OLEAN ST
Practice Address - Street 2:SUITE 220
Practice Address - City:EAST AURORA
Practice Address - State:NY
Practice Address - Zip Code:14052-2540
Practice Address - Country:US
Practice Address - Phone:716-805-1072
Practice Address - Fax:716-805-1073
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101238905207Q00000X
NY257093-1207Q00000X
OH091622207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2845032Medicaid
OH7171378OtherCIGNA
OH7171378OtherCIGNA
OH2845032Medicaid
OH4242361Medicare PIN
P00818355Medicare PIN