Individual
DR. JERRY M WEIDA
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
3005 GREENBUSH ST, LAFAYETTE, IN 47904-2435
(765) 447-3103
(765) 449-4782
Mailing address
3005 GREENBUSH ST, LAFAYETTE, IN 47904-2435
(765) 447-3103
(765) 449-4782
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
01020537
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000375909
ANTHEM PROVIDER NUMBER
IN
05
—
100230480A
—
IN
Enumeration date
09/13/2005
Last updated
11/03/2020
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