Provider Demographics
NPI:1306890785
Name:WEINBERG, JERRY C (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:C
Last Name:WEINBERG
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 1:236A MOORE STREET
Mailing Address - Street 2:PENNSPORT MALL
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19148
Mailing Address - Country:US
Mailing Address - Phone:215-755-9470
Mailing Address - Fax:215-755-9860
Practice Address - Street 1:1215 AVENUE M
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-5245
Practice Address - Country:US
Practice Address - Phone:718-965-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD028446E207W00000X
NY219927207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0009468220003Medicaid
NY02196234Medicaid
PA0009468220003Medicaid
PA434604Medicare ID - Type Unspecified
NY02196234Medicaid