Provider Demographics
NPI:1265419881
Name:WEISS, RICHARD D (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:D
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 1:230 E DAY RD
Mailing Address - Street 2:100
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-3408
Mailing Address - Country:US
Mailing Address - Phone:574-271-3939
Mailing Address - Fax:574-271-3941
Practice Address - Street 1:230 E DAY RD
Practice Address - Street 2:100
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3408
Practice Address - Country:US
Practice Address - Phone:574-271-3939
Practice Address - Fax:574-271-3941
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01027188A207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01027188AOtherPHYSICIAN LICENSE
INP00014933OtherRR MEDICARE
IN100222520Medicaid
IN4823160004Medicare NSC
IN100222520Medicaid
IN4823160003Medicare NSC
IN01027188AOtherPHYSICIAN LICENSE
INP00014933OtherRR MEDICARE
IN204460AMedicare ID - Type Unspecified