Provider Demographics
NPI:1851349039
Name:WEISE, EDMUND R (MD)
Entity Type:Individual
Prefix:DR
First Name:EDMUND
Middle Name:R
Last Name:WEISE
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 1:936 WAVERLY BLUFF CT
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-2200
Mailing Address - Country:US
Mailing Address - Phone:904-406-4811
Mailing Address - Fax:
Practice Address - Street 1:274 3RD AVE S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-6727
Practice Address - Country:US
Practice Address - Phone:904-249-3373
Practice Address - Fax:904-249-3371
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME8046208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL264895400Medicaid
FL16514Medicare ID - Type UnspecifiedMEDICARE
FL264895400Medicaid