Provider Demographics
NPI:1821058124
Name:WEITZMAN, LEE B (MD)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:B
Last Name:WEITZMAN
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 1:325 W PARK AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-3223
Mailing Address - Country:US
Mailing Address - Phone:516-432-2004
Mailing Address - Fax:516-432-4154
Practice Address - Street 1:325 W PARK AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-3223
Practice Address - Country:US
Practice Address - Phone:516-432-2004
Practice Address - Fax:516-432-4154
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY139593207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00767813Medicaid
NY85A091Medicare PIN
NY00767813Medicaid