Provider Demographics
NPI:1750496774
Name:WEBER, MIRYAM (MD)
Entity Type:Individual
Prefix:
First Name:MIRYAM
Middle Name:
Last Name:WEBER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 CEDAR ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-4369
Mailing Address - Country:US
Mailing Address - Phone:831-227-5715
Mailing Address - Fax:
Practice Address - Street 1:412 CEDAR ST
Practice Address - Street 2:SUITE A
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-4369
Practice Address - Country:US
Practice Address - Phone:831-227-5715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA724522084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A724520Medicaid
CAA72452OtherMEDICAL LICENSE #
CABW6860286OtherDEA #
CAH61036Medicare UPIN
CA00A724520Medicaid