Provider Demographics
NPI:1811941107
Name:WEISBERG, JAN J (MD)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:J
Last Name:WEISBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 PHYSICIANS PARK
Mailing Address - Street 2:SUITE 4
Mailing Address - City:FRANKFORT
Mailing Address - State:KY
Mailing Address - Zip Code:40601-4163
Mailing Address - Country:US
Mailing Address - Phone:502-227-9911
Mailing Address - Fax:502-226-6455
Practice Address - Street 1:5 PHYSICIANS PARK
Practice Address - Street 2:SUITE 4
Practice Address - City:FRANKFORT
Practice Address - State:KY
Practice Address - Zip Code:40601-4163
Practice Address - Country:US
Practice Address - Phone:502-227-9911
Practice Address - Fax:502-226-6455
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY26843207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY010026106OtherRAILROAD MEDICARE
KY311406300OtherU.S. DEPT. OF LABOR
KY1163158OtherCHA HEALTH
KY000000049298OtherANTHEM PIN
KY611166127OtherBLUEGRASS FAMILY HEALTH
KY64268436Medicaid
KY000000049298OtherANTHEM PIN
A43134Medicare UPIN