Basic Information
| Provider Information | |||||||||
| NPI: | 1093705048 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEISS | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 863407 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328863407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9419172600 | ||||||||
| FaxNumber: | 9419177884 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 BROTHER GEENEN WAY | ||||||||
| Address2: | |||||||||
| City: | SARASOTA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342367102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9415563220 | ||||||||
| FaxNumber: | 9419558214 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2005 | ||||||||
| LastUpdateDate: | 08/22/2019 | ||||||||
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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 | 207R00000X | ME19335 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 05327 | 01 | FL | BCBS | OTHER | 056000600 | 05 | FL | MEDICAID |