Provider Demographics
NPI:1982712717
Name:WEISS, MATTHEW JAY (DO)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JAY
Last Name:WEISS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9463 HOLLY RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439
Mailing Address - Country:US
Mailing Address - Phone:810-603-3702
Mailing Address - Fax:810-603-3704
Practice Address - Street 1:9463 HOLLY RD
Practice Address - Street 2:SUITE 103
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439
Practice Address - Country:US
Practice Address - Phone:810-603-3702
Practice Address - Fax:810-603-3704
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007703207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3371370Medicaid
0N16890001Medicare ID - Type Unspecified
MI3371370Medicaid