1174507164 NPI number — DOUGLAS K WEITZMAN M.D.

Table of content: DOUGLAS K WEITZMAN M.D. (NPI 1174507164)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174507164 NPI number — DOUGLAS K WEITZMAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEITZMAN
Provider First Name:
DOUGLAS
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174507164
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20209 SENTARA WAY STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARROLLTON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23314-3574
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-542-2000
Provider Business Mailing Address Fax Number:
757-542-2001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20209 SENTARA WAY STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARROLLTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23314-3574
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-542-2000
Provider Business Practice Location Address Fax Number:
757-542-2001
Provider Enumeration Date:
12/02/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  0101040484 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 381159 . This is a "ANTHEM PROVIDER NUMBER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 7300743 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 41040 . This is a "OPTIMA HEALTH PROVIDER NO" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".