Basic Information
| Provider Information | |||||||||
| NPI: | 1659339240 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEISSMAN | ||||||||
| FirstName: | IAN | ||||||||
| MiddleName: | ALLAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1660 N PROSPECT AVE | ||||||||
| Address2: | #2207 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532022400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142897662 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2925 W OKLAHOMA AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532154329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146496430 | ||||||||
| FaxNumber: | 4146495563 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 47301 | WI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 43517500 | 05 | WI | MEDICAID |