Provider Demographics
NPI:1154314235
Name:WEBER, DANIEL J (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:J
Last Name:WEBER
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 1:1571 WASHINGTON ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-9304
Mailing Address - Country:US
Mailing Address - Phone:315-786-5046
Mailing Address - Fax:
Practice Address - Street 1:1571 WASHINGTON ST
Practice Address - Street 2:SUITE 101
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-9304
Practice Address - Country:US
Practice Address - Phone:315-786-5046
Practice Address - Fax:315-786-5043
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1461412085R0202X
NY14614112085R0203X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B81249Medicare UPIN