Provider Demographics
NPI:1972501237
Name:WEINMAN, TAY JUSTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:TAY
Middle Name:JUSTIN
Last Name:WEINMAN
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 1:571 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-3115
Mailing Address - Country:US
Mailing Address - Phone:310-833-1327
Mailing Address - Fax:310-833-0698
Practice Address - Street 1:571 W 7TH ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-3115
Practice Address - Country:US
Practice Address - Phone:310-833-1327
Practice Address - Fax:310-833-0698
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-11
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG14368207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G143680Medicaid
CAA39241Medicare UPIN
CA00G143680Medicaid