Provider Demographics
NPI:1720168842
Name:WEISS, YAACOV
Entity Type:Individual
Prefix:
First Name:YAACOV
Middle Name:
Last Name:WEISS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 MADISON AVE
Mailing Address - Street 2:SUITE 11E
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-5421
Mailing Address - Country:US
Mailing Address - Phone:212-750-7404
Mailing Address - Fax:212-750-7404
Practice Address - Street 1:161 MADISON AVE
Practice Address - Street 2:SUITE 11E
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-5421
Practice Address - Country:US
Practice Address - Phone:212-750-7404
Practice Address - Fax:212-750-7404
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY203567174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG99153Medicare UPIN
NY54B691Medicare ID - Type Unspecified