Provider Demographics
NPI:1639252398
Name:WEISS, DERIC O (MD)
Entity Type:Individual
Prefix:
First Name:DERIC
Middle Name:O
Last Name:WEISS
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 1:915 HIGHLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-6902
Mailing Address - Country:US
Mailing Address - Phone:406-414-1720
Mailing Address - Fax:
Practice Address - Street 1:937 HIGHLAND BLVD
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-6909
Practice Address - Country:US
Practice Address - Phone:406-414-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT8263207R00000X, 207RH0002X
WAMD60406454207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP01309234OtherRR MEDICARE
MT000014401OtherBCBS PIN
WY112669500OtherMDCD PIN
MT0011237OtherMDCD PIN
WAP01309234OtherRR MEDICARE
WY112669500OtherMDCD PIN
WAP01309234OtherRR MEDICARE
47-4717998OtherTIN
MT000083018Medicare PIN
MT110178536Medicare PIN