Provider Demographics
NPI:1053581421
Name:WEIL, MARYJANE (OD)
Entity type:Individual
Prefix:DR
First Name:MARYJANE
Middle Name:
Last Name:WEIL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 TICONDEROGA DR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-3454
Mailing Address - Country:US
Mailing Address - Phone:970-377-1090
Mailing Address - Fax:970-493-9309
Practice Address - Street 1:1625 TICONDEROGA DR
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-3454
Practice Address - Country:US
Practice Address - Phone:970-377-1090
Practice Address - Fax:970-493-9309
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-02
Last Update Date:2008-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2460152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
804282OtherMEDICARE #
486668OtherMEDICARE GROUP
486668OtherMEDICARE GROUP