Provider Demographics
NPI:1891781019
Name:WEISS, BRIAN J (DPM)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
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 1:5035 MAYFIELD RD
Mailing Address - Street 2:SUITE #215
Mailing Address - City:LYNDHURST
Mailing Address - State:OH
Mailing Address - Zip Code:44124-2688
Mailing Address - Country:US
Mailing Address - Phone:440-382-8070
Mailing Address - Fax:216-382-6767
Practice Address - Street 1:5035 MAYFIELD RD
Practice Address - Street 2:SUITE #215
Practice Address - City:LYNDHURST
Practice Address - State:OH
Practice Address - Zip Code:44124-2688
Practice Address - Country:US
Practice Address - Phone:440-382-8070
Practice Address - Fax:216-382-6767
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-22
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36-00-2169-W213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0678306Medicaid
OH4613730001Medicare NSC
OHT80782Medicare UPIN
OH0678306Medicaid
OH480015843Medicare PIN