Provider Demographics
NPI:1063497824
Name:WIELKIEWICZ, WALTER (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:
Last Name:WIELKIEWICZ
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 1:860 BETHESDA DR
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-1800
Mailing Address - Country:US
Mailing Address - Phone:740-454-4651
Mailing Address - Fax:740-454-4653
Practice Address - Street 1:751 FOREST AVE STE 402
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-2878
Practice Address - Country:US
Practice Address - Phone:740-454-0196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35052245W207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH311413469055OtherCARESOURCE PIN
OH0101533OtherUHC PIN
OH0596789Medicaid
OH000000177605OtherUNISON PIN
OH0989499OtherGROUP MEDICAID
CA1586OtherGROUP MEDICARE RAILROAD
OH000000019630OtherANTHEM PIN
OH080019531OtherMEDICARE RAILROAD
OH080019531OtherMEDICARE RAILROAD
OH0596789Medicaid
OH311413469055OtherCARESOURCE PIN