Provider Demographics
NPI:1770580409
Name:WEINER, IRA LEWIS (MD)
Entity type:Individual
Prefix:
First Name:IRA
Middle Name:LEWIS
Last Name:WEINER
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 1:345 MOONLIGHT BAY DRIVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32407
Mailing Address - Country:US
Mailing Address - Phone:850-236-8862
Mailing Address - Fax:850-236-8862
Practice Address - Street 1:345 MOONLIGHT BAY DR
Practice Address - Street 2:
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32407-2860
Practice Address - Country:US
Practice Address - Phone:850-236-8862
Practice Address - Fax:850-236-8862
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME828072084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME82807OtherMEDICAL LICENSE #
FL81168OtherBCBSF PROV#
FL81168OtherBCBSF PROV#
FLD03289Medicare UPIN