Provider Demographics
NPI:1265595607
Name:WEITZ, BERNARD (OD)
Entity type:Individual
Prefix:
First Name:BERNARD
Middle Name:
Last Name:WEITZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4820 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220
Mailing Address - Country:US
Mailing Address - Phone:718-439-7070
Mailing Address - Fax:718-439-0270
Practice Address - Street 1:4820 5TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220
Practice Address - Country:US
Practice Address - Phone:718-439-7070
Practice Address - Fax:718-439-0270
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003596152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00343908Medicaid
NY00343908Medicaid
T89818Medicare UPIN