Provider Demographics
NPI:1215495569
Name:WEILAND, SCOTT DOUGLAS (TCH)
Entity type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:DOUGLAS
Last Name:WEILAND
Suffix:
Gender:M
Credentials:TCH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 MAIN ST APT 2
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07821-4578
Mailing Address - Country:US
Mailing Address - Phone:973-903-4767
Mailing Address - Fax:
Practice Address - Street 1:39 LAKESIDE BLVD
Practice Address - Street 2:
Practice Address - City:HOPATCONG
Practice Address - State:NJ
Practice Address - Zip Code:07843-1311
Practice Address - Country:US
Practice Address - Phone:862-707-8188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-06
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1120215174400000X
NJ1120216174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1120215Medicaid
NJ1120216Medicaid