Provider Demographics
NPI:1104880699
Name:WEASEN, STEVEN R (MD)
Entity type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:R
Last Name:WEASEN
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 1:258 BEN FRANKLIN HWY E
Mailing Address - Street 2:
Mailing Address - City:BIRDSBORO
Mailing Address - State:PA
Mailing Address - Zip Code:19508-8772
Mailing Address - Country:US
Mailing Address - Phone:610-288-2908
Mailing Address - Fax:610-898-4832
Practice Address - Street 1:1930 S BROAD ST STE 21
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-2328
Practice Address - Country:US
Practice Address - Phone:215-463-3939
Practice Address - Fax:877-437-7288
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD033733E207N00000X
NJ51083174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0057100000Medicare UPIN
PAWE152489Medicare ID - Type Unspecified
PAC32039Medicare UPIN