Provider Demographics
NPI:1851325294
Name:WEISS, LARRY (DPM)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:WEISS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17421 GREENFIELD RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-3700
Mailing Address - Country:US
Mailing Address - Phone:313-273-7091
Mailing Address - Fax:313-273-7694
Practice Address - Street 1:17421 GREENFIELD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235
Practice Address - Country:US
Practice Address - Phone:313-273-7091
Practice Address - Fax:313-273-7694
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI382244642213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI382244642OtherTAX ID
MI1485013Medicaid
MI0M22500Medicare PIN
MI382244642OtherTAX ID
MI0899490001Medicare NSC