Provider Demographics
NPI:1659349280
Name:WEISS, LEE DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:DAVID
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 1:1341 WARREN AVENUE
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-3437
Mailing Address - Country:US
Mailing Address - Phone:630-719-5454
Mailing Address - Fax:630-719-1263
Practice Address - Street 1:7234 WEST OGDEN AVENUE
Practice Address - Street 2:SUITE 3N
Practice Address - City:RIVERSIDE
Practice Address - State:IL
Practice Address - Zip Code:60546-2387
Practice Address - Country:US
Practice Address - Phone:708-447-2277
Practice Address - Fax:708-447-2274
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360443692084P0800X
IL036.0443692084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL211323007OtherPTAN
IL211324005OtherPTAN
IL036044369Medicaid
IL036044369Medicaid