Basic Information
| Provider Information | |||||||||
| NPI: | 1568466258 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEINGARTEN | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | L | ||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1135 W UNIVERSITY DR | ||||||||
| Address2: | STE 210 | ||||||||
| City: | ROCHESTER HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483071872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486504660 | ||||||||
| FaxNumber: | 2486504663 | ||||||||
| Practice Location | |||||||||
| Address1: | 2799 W GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482022608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006536568 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2005 | ||||||||
| LastUpdateDate: | 09/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/15/2006 | ||||||||
| NPIReactivationDate: | 03/22/2006 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 4301402858 | MI | Y | Allopathic & Osteopathic Physicians | Urology | 174400000X | JW402858 | MI | N | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 2823213 | 05 | MI | MEDICAID | JW402858 | 01 | MI | STATE LICENSE | OTHER |