Provider Demographics
NPI:1639538069
Name:WEISS, MALCOLM D (DO)
Entity Type:Individual
Prefix:
First Name:MALCOLM
Middle Name:D
Last Name:WEISS
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 1:4633 RIVERWALK VILLAGE CT
Mailing Address - Street 2:
Mailing Address - City:PONCE INLET
Mailing Address - State:FL
Mailing Address - Zip Code:32127-2700
Mailing Address - Country:US
Mailing Address - Phone:717-870-2244
Mailing Address - Fax:
Practice Address - Street 1:4633 RIVERWALK VILLAGE CT
Practice Address - Street 2:
Practice Address - City:PONCE INLET
Practice Address - State:FL
Practice Address - Zip Code:32127-2700
Practice Address - Country:US
Practice Address - Phone:717-870-2244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-12
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS002826L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine