Basic Information
Provider Information | |||||||||
NPI: | 1548201643 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WEITZMANN | ||||||||
FirstName: | JONATHAN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 110 N 29TH ST | ||||||||
Address2: | STE. 201 | ||||||||
City: | NORFOLK | ||||||||
State: | NE | ||||||||
PostalCode: | 687014424 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4028448121 | ||||||||
FaxNumber: | 4028448122 | ||||||||
Practice Location | |||||||||
Address1: | 110 N 29TH ST | ||||||||
Address2: | STE. 303 | ||||||||
City: | NORFOLK | ||||||||
State: | NE | ||||||||
PostalCode: | 687014461 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4028448131 | ||||||||
FaxNumber: | 4028448130 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/09/2006 | ||||||||
LastUpdateDate: | 04/09/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 23007 | NE | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
ID | Type | State | Issuer | Description | P00192908 | 01 | NE | RR | OTHER | 06222 | 01 | NE | BCBSNE | OTHER |