Provider Demographics
NPI:1861415887
Name:WEISS, KENNETH JOEL (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:JOEL
Last Name:WEISS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9890 MAIN STREET REAR
Mailing Address - Street 2:
Mailing Address - City:DAMASCUS
Mailing Address - State:MD
Mailing Address - Zip Code:20872-2087
Mailing Address - Country:US
Mailing Address - Phone:301-253-6977
Mailing Address - Fax:301-253-9091
Practice Address - Street 1:9890 MAIN STREET REAR
Practice Address - Street 2:
Practice Address - City:DAMASCUS
Practice Address - State:MD
Practice Address - Zip Code:20872-2087
Practice Address - Country:US
Practice Address - Phone:301-253-6977
Practice Address - Fax:301-253-9091
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0014097208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
408338Medicare ID - Type Unspecified
C88627Medicare UPIN