Provider Demographics
NPI:1679591770
Name:WEITZ, JEFFREY
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:WEITZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 SEABLUFF
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-9103
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19 SEABLUFF
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-9103
Practice Address - Country:US
Practice Address - Phone:949-854-2294
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG572182085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1679591770Medicaid
CAWG57218MMedicare PIN
CA00G572182Medicare PIN
CAAR261VMedicare PIN
CAAR261YMedicare PIN
CAWG57218JMedicare PIN
E85706Medicare UPIN
CAAO768Medicare PIN
CAAO768YMedicare PIN
CAWG57218IMedicare PIN
CAWG57218LMedicare PIN
CAAR261ZMedicare PIN
CA00G572181Medicare PIN
CA1679591770Medicaid
CAAR261XMedicare PIN