Provider Demographics
NPI:1780612028
Name:WEISS, MICHAEL ERIC (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ERIC
Last Name:WEISS
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:PO BOX 635002
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5002
Mailing Address - Country:US
Mailing Address - Phone:800-424-3672
Mailing Address - Fax:954-377-3042
Practice Address - Street 1:3501 JOHNSON STREEET
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021
Practice Address - Country:US
Practice Address - Phone:954-987-2000
Practice Address - Fax:954-985-3453
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME75622208000000X, 2080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL256533100Medicaid
FL46732OtherBLUE SHIELD
G938817Medicare UPIN
FLA63396Medicare UPIN
FL256533100Medicaid