Provider Demographics
NPI:1962551127
Name:WEINER, MARC (DPM)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:WEINER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2035 WICKFORD CT
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-1088
Mailing Address - Country:US
Mailing Address - Phone:248-701-3774
Mailing Address - Fax:
Practice Address - Street 1:2035 WICKFORD CT
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-1088
Practice Address - Country:US
Practice Address - Phone:248-701-3774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMW000841213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIT34411Medicare UPIN
MI0N28240Medicare ID - Type Unspecified