Provider Demographics
NPI:1629104807
Name:WEILL, DAVID (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:WEILL
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:PO BOX 611484
Mailing Address - Street 2:
Mailing Address - City:ROSEMARY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32461-1004
Mailing Address - Country:US
Mailing Address - Phone:650-862-3432
Mailing Address - Fax:
Practice Address - Street 1:12901 BRUCE B DOWNS BLVD
Practice Address - Street 2:MDC BOX 62
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-4742
Practice Address - Country:US
Practice Address - Phone:813-974-0483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-24
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC52127207RP1001X
FLME130463207RP1001X
LA304283204F00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020028900Medicaid
CA00C521270Medicaid
FLQSBYQOtherBLUE CROSS BLUE SHIELD
CA00C521270Medicaid
FLQSBYQOtherBLUE CROSS BLUE SHIELD