Provider Demographics
NPI:1659339240
Name:WEISSMAN, IAN ALLAN (DO)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:ALLAN
Last Name:WEISSMAN
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 1:1660 N PROSPECT AVE
Mailing Address - Street 2:#2207
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-2400
Mailing Address - Country:US
Mailing Address - Phone:414-289-7662
Mailing Address - Fax:
Practice Address - Street 1:2925 W OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4329
Practice Address - Country:US
Practice Address - Phone:414-649-6430
Practice Address - Fax:414-649-5563
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI473012085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43517500Medicaid
WI73710Medicare ID - Type Unspecified
WI43517500Medicaid