Provider Demographics
NPI:1902840820
Name:WEISS, RICHARD J (DPM)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
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 1:800 AUSTIN ST
Mailing Address - Street 2:SUITE 469
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-3439
Mailing Address - Country:US
Mailing Address - Phone:847-328-3338
Mailing Address - Fax:847-328-3388
Practice Address - Street 1:800 AUSTIN ST
Practice Address - Street 2:SUITE 469
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-3439
Practice Address - Country:US
Practice Address - Phone:847-328-3338
Practice Address - Fax:847-328-3388
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003961213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016003961Medicaid
IL480013147Medicare PIN
IL753600001Medicare PIN
IL560760002Medicare PIN
T59882Medicare UPIN
IL016003961Medicaid
K01462Medicare ID - Type Unspecified
IL560750001Medicare PIN
IL560770001Medicare PIN