Provider Demographics
NPI:1932428406
Name:WEISMAN, MARK STEPHEN JR (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:STEPHEN
Last Name:WEISMAN
Suffix:JR
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 1:1324 LAKELAND HILLS BLVD
Mailing Address - Street 2:MANAGED CARE DEPT
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:930 ALICIA RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-2104
Practice Address - Country:US
Practice Address - Phone:833-769-3524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-24
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1121822084P0800X
FLME1121822084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry