Provider Demographics
NPI:1508844143
Name:WETZ, ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:WETZ
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 1:1 EDGEWATER ST
Mailing Address - Street 2:6TH FL. PAYER RELATIONS
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-4900
Mailing Address - Country:US
Mailing Address - Phone:718-226-1008
Mailing Address - Fax:718-226-1039
Practice Address - Street 1:242 MASON AVE
Practice Address - Street 2:SUITE 2B
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3408
Practice Address - Country:US
Practice Address - Phone:781-226-6494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY214932207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP00471059OtherRAILROAD MEDICARE
NY02092157Medicaid
NY02092157Medicaid