Provider Demographics
NPI:1609843499
Name:WEISE, MARC W (MD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:W
Last Name:WEISE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2 JAMES WAY
Mailing Address - Street 2:SUITE 115
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-4973
Mailing Address - Country:US
Mailing Address - Phone:805-773-2650
Mailing Address - Fax:805-773-2655
Practice Address - Street 1:2 JAMES WAY
Practice Address - Street 2:SUITE 115
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-4973
Practice Address - Country:US
Practice Address - Phone:805-773-2650
Practice Address - Fax:805-773-2655
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-01
Last Update Date:2010-06-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA44223207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
611373100OtherUSDL PIN
CAA44223OtherBLUE CROSS
CA00A442230OtherBLUE SHIELD
CA00A442230Medicaid
7941133OtherAETNA
786185OtherCCN/FIRST HEALTH
5684480001Medicare NSC
786185OtherCCN/FIRST HEALTH
WA44223BMedicare PIN
POO323074Medicare PIN