Provider Demographics
NPI:1184707119
Name:WEISS, MARY B (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:B
Last Name:WEISS
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 1:904 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-1132
Mailing Address - Country:US
Mailing Address - Phone:206-860-2209
Mailing Address - Fax:206-720-7435
Practice Address - Street 1:904 7TH AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-1132
Practice Address - Country:US
Practice Address - Phone:206-860-2209
Practice Address - Fax:206-720-7435
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00027537207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8127490Medicaid
WAG8950805Medicare PIN
E 98243Medicare UPIN
WA8127490Medicaid