Provider Demographics
NPI:1669494035
Name:WEITMAN, CARL USHER (PHD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:USHER
Last Name:WEITMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25221 MILES RD
Mailing Address - Street 2:SUITE F
Mailing Address - City:WARRENSVILLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44128-5474
Mailing Address - Country:US
Mailing Address - Phone:216-586-9319
Mailing Address - Fax:216-831-8492
Practice Address - Street 1:25221 MILES RD
Practice Address - Street 2:SUITE F
Practice Address - City:WARRENSVILLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44128-5474
Practice Address - Country:US
Practice Address - Phone:216-586-9319
Practice Address - Fax:216-831-8492
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1145103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0275625Medicaid
OH34-1310356OtherFEDERAL TAX ID NUMBER
OH34-1310356OtherFEDERAL TAX ID NUMBER