Provider Demographics
NPI:1366513947
Name:WEISE, MICHAEL DAVID
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:WEISE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MARTIN CT
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:MD
Mailing Address - Zip Code:21601-3833
Mailing Address - Country:US
Mailing Address - Phone:410-822-2250
Mailing Address - Fax:410-820-9537
Practice Address - Street 1:1 MARTIN CT
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-3833
Practice Address - Country:US
Practice Address - Phone:410-822-2250
Practice Address - Fax:410-820-9537
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0653190001Medicare ID - Type Unspecified