Provider Demographics
NPI:1821096280
Name:WEISS, ALLEN M (MPT,ATC/L)
Entity Type:Individual
Prefix:
First Name:ALLEN
Middle Name:M
Last Name:WEISS
Suffix:
Gender:M
Credentials:MPT,ATC/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2140 KINGSLEY AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-5180
Mailing Address - Country:US
Mailing Address - Phone:904-215-3958
Mailing Address - Fax:904-215-3970
Practice Address - Street 1:1835-16 EAST WEST PARKWAY
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32003-7450
Practice Address - Country:US
Practice Address - Phone:904-215-3958
Practice Address - Fax:904-215-3970
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT15505225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY7919ZMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER