Provider Demographics
NPI:1215935697
Name:WEIDENTHAL, DANIEL TILLES (MD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:TILLES
Last Name:WEIDENTHAL
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 1:25700 SCIENCE PARK DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-7319
Mailing Address - Country:US
Mailing Address - Phone:216-464-5266
Mailing Address - Fax:216-464-5290
Practice Address - Street 1:25700 SCIENCE PARK DR
Practice Address - Street 2:SUITE 190
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-7319
Practice Address - Country:US
Practice Address - Phone:216-464-5266
Practice Address - Fax:216-464-5290
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35023014W208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000126756OtherANTHEM
OH0080095Medicaid
OHWE0117061Medicare ID - Type Unspecified
OH0080095Medicaid