Provider Demographics
NPI:1942252226
Name:WEIS, JUDITH K (MD)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:K
Last Name:WEIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:739 N JEFFERSON ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MASCOUTAH
Mailing Address - State:IL
Mailing Address - Zip Code:62258-1447
Mailing Address - Country:US
Mailing Address - Phone:618-566-8810
Mailing Address - Fax:618-566-7121
Practice Address - Street 1:739 N JEFFERSON ST
Practice Address - Street 2:SUITE 200
Practice Address - City:MASCOUTAH
Practice Address - State:IL
Practice Address - Zip Code:62258-1447
Practice Address - Country:US
Practice Address - Phone:618-566-8810
Practice Address - Fax:618-566-7121
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036089439207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036089439Medicaid
IL382430Medicare ID - Type Unspecified
ILG09275Medicare UPIN