Provider Demographics
NPI:1821083288
Name:WEIDA, JERRY M (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:M
Last Name:WEIDA
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 1:3005 GREENBUSH ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-2435
Mailing Address - Country:US
Mailing Address - Phone:765-447-3103
Mailing Address - Fax:765-449-4782
Practice Address - Street 1:3005 GREENBUSH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2435
Practice Address - Country:US
Practice Address - Phone:765-447-3103
Practice Address - Fax:765-449-4782
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01020537207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000375909OtherANTHEM PROVIDER NUMBER
IN100230480AMedicaid
IN233650AMedicare PIN
C25687Medicare UPIN
INP00268611Medicare PIN