Provider Demographics
NPI:1356398952
Name:WEITZ, THEODORE I (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:I
Last Name:WEITZ
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 1:240 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WOLFEBORO
Mailing Address - State:NH
Mailing Address - Zip Code:03894-4411
Mailing Address - Country:US
Mailing Address - Phone:603-569-7500
Mailing Address - Fax:
Practice Address - Street 1:117 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26847-9566
Practice Address - Country:US
Practice Address - Phone:304-257-1026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV25991207P00000X
MO2005030572207P00000X
NMMD2008-0651207P00000X
WI18315207P00000X, 208D00000X
MA212862208000000X
NHLT-1161207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice