Provider Demographics
NPI:1649344532
Name:WEISS, STEPHEN PHILIP (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:PHILIP
Last Name:WEISS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:66 AVENIDA ALDEA
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507
Mailing Address - Country:US
Mailing Address - Phone:505-795-7111
Mailing Address - Fax:505-438-0668
Practice Address - Street 1:66 AVENIDA ALDEA
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507
Practice Address - Country:US
Practice Address - Phone:505-795-7111
Practice Address - Fax:505-438-0668
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM91-137175L00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No175L00000XOther Service ProvidersHomeopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMF21695Medicare UPIN