Provider Demographics
NPI:1174541726
Name:WEISS, MARK R (DPM)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:R
Last Name:WEISS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
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Mailing Address - Street 1:2080 CENTURY PARK E
Mailing Address - Street 2:SUITE #605
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90067-2001
Mailing Address - Country:US
Mailing Address - Phone:310-553-7371
Mailing Address - Fax:310-553-9722
Practice Address - Street 1:2080 CENTURY PARK E
Practice Address - Street 2:SUITE #605
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90067-2001
Practice Address - Country:US
Practice Address - Phone:310-553-7371
Practice Address - Fax:310-553-9722
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAE1442213ES0103X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT10955Medicare UPIN
WE11300Medicare PIN
CA4905500001Medicare NSC
CAWE1442AMedicare PIN