Provider Demographics
NPI:1194785642
Name:WEISMAN, KENNETH (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:WEISMAN
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 1:201 N MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:PLAINVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06062-1848
Mailing Address - Country:US
Mailing Address - Phone:740-374-4500
Mailing Address - Fax:740-374-5887
Practice Address - Street 1:400 MATTHEW ST
Practice Address - Street 2:SUITE 303
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-1644
Practice Address - Country:US
Practice Address - Phone:740-373-7828
Practice Address - Fax:740-373-5898
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-27
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT47702208800000X
OH35.097897208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000728272OtherANTHEM
OH0052750Medicaid
WV3810021225Medicaid
OHP01216329OtherRAILROAD MEDICARE
OH000000727239OtherANTHEM
OHH019671Medicare PIN
OHH019670Medicare PIN