Provider Demographics
NPI:1629189816
Name:WEITZEL, MARTIN KRESS (DO)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:KRESS
Last Name:WEITZEL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 COLUMBUS ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021
Mailing Address - Country:US
Mailing Address - Phone:315-255-3944
Mailing Address - Fax:
Practice Address - Street 1:91 COLUMBUS ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021
Practice Address - Country:US
Practice Address - Phone:315-255-3944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY170457207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01023683Medicaid
NYJ400039019Medicare PIN
B82957Medicare UPIN
NY5080313Medicare ID - Type Unspecified