Provider Demographics
NPI:1659304319
Name:WEISMAN, EVAN B (MD)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:B
Last Name:WEISMAN
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 68
Mailing Address - Street 2:
Mailing Address - City:S WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02190-0001
Mailing Address - Country:US
Mailing Address - Phone:781-843-0705
Mailing Address - Fax:781-843-3809
Practice Address - Street 1:340 WOOD RD STE 101
Practice Address - Street 2:
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-2404
Practice Address - Country:US
Practice Address - Phone:781-843-0705
Practice Address - Fax:781-843-3809
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA156689207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MABX8381OtherMEDICARE PTAN
MA31910021Medicaid
MAA2904601OtherMEDICARE PTAN
MA31910021Medicaid