Provider Demographics
NPI:1689788648
Name:WEISMAN, MITCHELL LEE (MD)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:LEE
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 1:6967 108TH ST
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-3846
Mailing Address - Country:US
Mailing Address - Phone:718-268-4932
Mailing Address - Fax:718-268-2395
Practice Address - Street 1:6967 108TH ST
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-3846
Practice Address - Country:US
Practice Address - Phone:718-268-4932
Practice Address - Fax:718-268-2395
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY179128225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01379464Medicaid
NY00485QMedicare ID - Type Unspecified
NY01379464Medicaid