Provider Demographics
NPI:1821082611
Name:WEINER, JAY (MD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:
Last Name:WEINER
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 1:79 SAND PIT RD
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-4005
Mailing Address - Country:US
Mailing Address - Phone:203-749-5700
Mailing Address - Fax:
Practice Address - Street 1:79 SAND PIT RD
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-4005
Practice Address - Country:US
Practice Address - Phone:203-749-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT15507174400000X
CT015507207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001155076Medicaid
CT110010112Medicare PIN
B38763Medicare UPIN
CT060000349Medicare ID - Type Unspecified