Provider Demographics
NPI:1710967328
Name:WEISS, GARY M (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:M
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 1:1051 PORT MALABAR BLVD NE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-5153
Mailing Address - Country:US
Mailing Address - Phone:321-727-9063
Mailing Address - Fax:321-728-1955
Practice Address - Street 1:1051 PORT MALABAR BLVD NE
Practice Address - Street 2:SUITE 6
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-5153
Practice Address - Country:US
Practice Address - Phone:321-727-9063
Practice Address - Fax:321-728-1955
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME399432084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL62367OtherBLUE CROSS BLUE SHIELD
FL066754400Medicaid
FL72173Medicare ID - Type UnspecifiedGROUP NUMBER
FL62367OtherBLUE CROSS BLUE SHIELD
FL066754400Medicaid