Provider Demographics
NPI:1285622662
Name:WEISE, RICHARD A (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:A
Last Name:WEISE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:607 N CENTRAL AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-1804
Mailing Address - Country:US
Mailing Address - Phone:818-956-1010
Mailing Address - Fax:818-543-6083
Practice Address - Street 1:607 N CENTRAL AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-1804
Practice Address - Country:US
Practice Address - Phone:818-956-1010
Practice Address - Fax:818-543-6083
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2013-09-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG45111207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ75843ZMedicaid
CAZZZ75843ZMedicaid
W13790Medicare ID - Type Unspecified