Basic Information
| Provider Information | |||||||||
| NPI: | 1376632158 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEISS | ||||||||
| FirstName: | JUDITH | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7350 INDUSTRIAL PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | MENTOR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440605318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2167329480 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6701 ROCKSIDE RD | ||||||||
| Address2: | SUITE 260 | ||||||||
| City: | INDEPENDENCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441312358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2163692525 | ||||||||
| FaxNumber: | 2163692531 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 09/12/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 16545 | NV | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | G68883 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 10681A | WY | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD60633801 | WA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 52042 | AZ | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MED-PHYS-LIC-44990 | MT | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | M-13196 | ID | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | DR.0057080 | CO | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD175712 | OR | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD2016-0808 | NM | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 114311 | AK | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD-18905 | HI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 35052437 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0944607 | 05 | OH | MEDICAID | 000000533747 | 01 | OH | ANTHEM | OTHER | 408442 | 01 | OH | WELLCARE | OTHER | 9006404 | 01 | OH | SUMMACARE | OTHER |