Provider Demographics
NPI:1790715399
Name:WEITZ, ILENE (MD)
Entity Type:Individual
Prefix:DR
First Name:ILENE
Middle Name:
Last Name:WEITZ
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:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-865-3105
Mailing Address - Fax:
Practice Address - Street 1:1441 EASTLAKE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-0112
Practice Address - Country:US
Practice Address - Phone:323-865-3105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG35326207RH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA830008689OtherRAILROAD MEDICARE
CACE1617OtherGROUP RAILROAD MEDICARE
CA1902846306OtherGROUP NPI
CAW18762OtherGROUP MEDICARE
CA1356390009OtherGROUP NPI
CAW11675OtherGROUP MEDICARE PIN
CA00G353260OtherBLUE SHIELD
CA00G353260Medicaid
CAGR0016910OtherGROUP MEDICAID PIN
CAGR0100430OtherGROUP MEDICAL
CAGR0016910OtherGROUP MEDICAID PIN
CAA46313Medicare UPIN