Provider Demographics
NPI:1174600258
Name:WEISS, GORDON S (MD)
Entity type:Individual
Prefix:DR
First Name:GORDON
Middle Name:S
Last Name:WEISS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:595 THOMPSON AVENUE
Mailing Address - Street 2:EAST HAVEN COUNSELING & COMMUNITY SERVICES
Mailing Address - City:EAST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06512
Mailing Address - Country:US
Mailing Address - Phone:203-468-3297
Mailing Address - Fax:203-468-3334
Practice Address - Street 1:595 THOMPSON AVENUE
Practice Address - Street 2:EAST HAVEN COUNSELING & COMMUNITY SERVICES
Practice Address - City:EAST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06512
Practice Address - Country:US
Practice Address - Phone:203-468-3297
Practice Address - Fax:203-468-3334
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT0353452084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
C01936Medicare ID - Type UnspecifiedAGENCY #