Provider Demographics
NPI:1912215708
Name:ALLAN GARY WEISS DPM A PROFESSIONAL CORP
Entity Type:Organization
Organization Name:ALLAN GARY WEISS DPM A PROFESSIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALLAN
Authorized Official - Middle Name:GARY
Authorized Official - Last Name:WEISS DPM
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:714-628-1995
Mailing Address - Street 1:705 W LA VETA AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4447
Mailing Address - Country:US
Mailing Address - Phone:714-628-1995
Mailing Address - Fax:714-628-1983
Practice Address - Street 1:705 W LA VETA AVE STE 100
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4447
Practice Address - Country:US
Practice Address - Phone:714-628-1995
Practice Address - Fax:714-628-1983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-15
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE1917213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT19147Medicare UPIN