Provider Demographics
NPI:1194734194
Name:WEISS, LARRY W (MD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:W
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 1:208 E CHURCH ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MARSHALLTOWN
Mailing Address - State:IA
Mailing Address - Zip Code:50158-2961
Mailing Address - Country:US
Mailing Address - Phone:641-752-9538
Mailing Address - Fax:641-753-2190
Practice Address - Street 1:208 E CHURCH ST
Practice Address - Street 2:SUITE 102
Practice Address - City:MARSHALLTOWN
Practice Address - State:IA
Practice Address - Zip Code:50158-2961
Practice Address - Country:US
Practice Address - Phone:641-752-9538
Practice Address - Fax:641-753-2190
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA20021207N00000X, 207NP0225X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0123562Medicaid
IA12356Medicare ID - Type Unspecified