Provider Demographics
NPI:1316132137
Name:WEITZENFELD, MARK B (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:B
Last Name:WEITZENFELD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2234 COLONIAL BLVD
Mailing Address - Street 2:ATTN: PAYER CONTRACTING & RELATIONS DEPT.
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:21110 BISCAYNE BLVD
Practice Address - Street 2:SUITE 401
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-1227
Practice Address - Country:US
Practice Address - Phone:305-933-1772
Practice Address - Fax:305-675-2788
Is Sole Proprietor?:No
Enumeration Date:2007-09-14
Last Update Date:2017-06-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME27164208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL56089OtherBLUE CROSS BLUE SHIELD
FL56089OtherBCBS
FLP971396OtherOPTIMUM
FL002364OtherNHP
FL0366037OtherCIGNA
FL1256832OtherWELLCARE MEDICARE ONLY
FLP00284474OtherRAILROAD MEDICARE
FL1005619OtherCAREPLUS
FL4200786OtherAETNA
FLP1035626OtherFREEDOM
FLP0001582OtherSIMPLY
FL203827OtherAVMED
FL2364OtherDIMENSION
FLP01609935OtherRR MEDICARE
FL040323700Medicaid
FLP01609935OtherRR MEDICARE
FLP00284474OtherRAILROAD MEDICARE
FLD56755Medicare UPIN
FL56089RMedicare PIN
FL56089PMedicare PIN