Provider Demographics
NPI:1730255241
Name:WEISS, ROGER A (PH D)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:A
Last Name:WEISS
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3178
Mailing Address - Street 2:
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96745-3178
Mailing Address - Country:US
Mailing Address - Phone:808-329-7999
Mailing Address - Fax:
Practice Address - Street 1:75 7544 ALII DR
Practice Address - Street 2:
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740
Practice Address - Country:US
Practice Address - Phone:808-329-7999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY267103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI01256-7Medicaid
HI01256-7Medicaid