1699793760 NPI number — SHELLEY ETHAN WEISS M.D.

Table of content: SHELLEY ETHAN WEISS M.D. (NPI 1699793760)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699793760 NPI number — SHELLEY ETHAN WEISS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEISS
Provider First Name:
SHELLEY
Provider Middle Name:
ETHAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1699793760
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/20/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 961205
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76161-1205
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-740-8450
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7777 FOREST LN STE C550
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75230-7518
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-566-4286
Provider Business Practice Location Address Fax Number:
972-566-8634
Provider Enumeration Date:
07/17/2006

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: 208000000X , with the licence number:  L0958 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 168133001 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 168133002 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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