Provider Demographics
NPI:1871760538
Name:WEISS, FREDERICK ETHAN (MD)
Entity type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:ETHAN
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 1:801 ALBANY ST FL G
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02119-3791
Mailing Address - Country:US
Mailing Address - Phone:617-414-5405
Mailing Address - Fax:
Practice Address - Street 1:701 W PLYMOUTH AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-3236
Practice Address - Country:US
Practice Address - Phone:386-943-3160
Practice Address - Fax:317-705-5047
Is Sole Proprietor?:No
Enumeration Date:2008-05-13
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME123132207LP2900X, 2085N0700X, 208VP0000X
MAETL70452085R0202X
FLME1551392085R0202X
390200000X
PAMD4480282085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program