Provider Demographics
NPI:1386605509
Name:WEISS, DAVID M (OD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:M
Last Name:WEISS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 OAK DR
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691
Mailing Address - Country:US
Mailing Address - Phone:718-523-0730
Mailing Address - Fax:718-523-6704
Practice Address - Street 1:165-01 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-4900
Practice Address - Country:US
Practice Address - Phone:718-523-0730
Practice Address - Fax:718-523-6704
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-29
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV4612152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01158525Medicaid
NY00701Medicare ID - Type Unspecified