Provider Demographics
NPI:1922180348
Name:WEINER, BARRY (MD)
Entity Type:Individual
Prefix:DR
First Name:BARRY
Middle Name:
Last Name:WEINER
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 1:20011 KENO AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLIS
Mailing Address - State:NY
Mailing Address - Zip Code:11423-1435
Mailing Address - Country:US
Mailing Address - Phone:718-465-8792
Mailing Address - Fax:
Practice Address - Street 1:109 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07304-3217
Practice Address - Country:US
Practice Address - Phone:201-434-0008
Practice Address - Fax:204-451-2863
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02569800207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2922801Medicaid
NJ2922801Medicaid