Basic Information
| Provider Information | |||||||||
| NPI: | 1356398952 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEITZ | ||||||||
| FirstName: | THEODORE | ||||||||
| MiddleName: | I | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 240 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WOLFEBORO | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038944411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035697500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 117 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | PETERSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 268479566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042571026 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2006 | ||||||||
| LastUpdateDate: | 02/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 25991 | WV | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 2005030572 | MO | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | MD2008-0651 | NM | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 18315 | WI | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 208000000X | 212862 | MA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208D00000X | 18315 | WI | N | Allopathic & Osteopathic Physicians | General Practice | 207P00000X | LT-1161 | NH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.