1598138612 NPI number — DR. JACOB ERNEST WEINBERG DMD, MDS

Table of content: DR. JACOB ERNEST WEINBERG DMD, MDS (NPI 1598138612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598138612 NPI number — DR. JACOB ERNEST WEINBERG DMD, MDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEINBERG
Provider First Name:
JACOB
Provider Middle Name:
ERNEST
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD, MDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598138612
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/11/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2730 SW MOODY AVE
Provider Second Line Business Mailing Address:
MAIL CODE: SD-PERI
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97201-5042
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-494-1352
Provider Business Mailing Address Fax Number:
503-494-5777

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2730 SW MOODY AVE
Provider Second Line Business Practice Location Address:
MAIL CODE: SD-PERI
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97201-5042
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-494-1352
Provider Business Practice Location Address Fax Number:
503-494-5777
Provider Enumeration Date:
11/11/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223P0300X , with the licence number:  D4090 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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