Provider Demographics
NPI:1689787442
Name:WEINER, JERRY W (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:W
Last Name:WEINER
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 1:1206 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336
Mailing Address - Country:US
Mailing Address - Phone:209-823-7874
Mailing Address - Fax:209-823-1709
Practice Address - Street 1:1206 E NORTH ST
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336
Practice Address - Country:US
Practice Address - Phone:209-823-7874
Practice Address - Fax:209-823-1709
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG559960208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G559960Medicaid
CA00G559960Medicaid
00G559960Medicare ID - Type Unspecified