Provider Demographics
NPI:1942210364
Name:WEISS, BARTLEY M (MD)
Entity Type:Individual
Prefix:
First Name:BARTLEY
Middle Name:M
Last Name:WEISS
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 1:1350 N 500 E
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-2400
Mailing Address - Country:US
Mailing Address - Phone:435-792-1950
Mailing Address - Fax:
Practice Address - Street 1:1350 N 500 E
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2400
Practice Address - Country:US
Practice Address - Phone:435-792-1950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1642111205208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000063593Medicare PIN
UTD07549Medicare UPIN