Basic Information
| Provider Information | |||||||||
| NPI: | 1053342386 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEINTRAUB | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2234 COLONIAL BLVD | ||||||||
| Address2: | ATTN: PAYER CONTRACTING & RELATIONS | ||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339071412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2399317342 | ||||||||
| FaxNumber: | 2399317385 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 3RD AVE W | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342058626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417920340 | ||||||||
| FaxNumber: | 9417942251 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 04/26/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | ME0068491 | FL | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 09134 | 01 | FL | UNIVERSAL | OTHER | P01040599 | 01 | FL | RAILROAD MCR | OTHER | 1193517 | 01 | FL | WELLCARE | OTHER | P102261 | 01 | FL | FREEDOM HEALTH | OTHER | 27451 | 01 | FL | BCBS FL | OTHER | 012776600 | 05 | FL | MEDICAID | 353795 | 01 | FL | AVMED | OTHER | 5103435 | 01 | FL | AETNA | OTHER | P939415 | 01 | FL | OPTIMUM | OTHER |