Provider Demographics
NPI:1962419358
Name:WEITZMAN, STEPHEN (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:
Last Name:WEITZMAN
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 1:36 ERLAND RD
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-1125
Mailing Address - Country:US
Mailing Address - Phone:631-751-9104
Mailing Address - Fax:
Practice Address - Street 1:36 ERLAND RD
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-1125
Practice Address - Country:US
Practice Address - Phone:631-751-8104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY107025207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00547264Medicaid
42A371Medicare ID - Type Unspecified
NY00547264Medicaid