Provider Demographics
NPI:1184616047
Name:WEINER, MARK J (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:J
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 1:1320 OAKSIDE DR
Mailing Address - Street 2:S202
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-2475
Mailing Address - Country:US
Mailing Address - Phone:770-720-4041
Mailing Address - Fax:770-479-4857
Practice Address - Street 1:1320 OAKSIDE DR
Practice Address - Street 2:S202
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-2475
Practice Address - Country:US
Practice Address - Phone:770-720-4041
Practice Address - Fax:770-479-4857
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-17
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA33748207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA581937175OtherTAX ID
GA000439348BMedicaid
GA180010817OtherRAILROAD MEDICARE
GA581937175OtherTAX ID
GAB98135Medicare UPIN
GA18BDCCVMedicare PIN