Provider Demographics
NPI:1033110895
Name:WIENER, BRADLEY D (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:D
Last Name:WIENER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 CRYSTAL RUN RD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10941-7000
Mailing Address - Country:US
Mailing Address - Phone:845-673-1080
Mailing Address - Fax:845-673-5320
Practice Address - Street 1:75 CRYSTAL RUN RD
Practice Address - Street 2:SUITE 206
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10941-7000
Practice Address - Country:US
Practice Address - Phone:845-673-1080
Practice Address - Fax:845-673-5320
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY200402207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY74G521Medicare ID - Type Unspecified
G45722Medicare UPIN
NY01738898Medicare ID - Type Unspecified