Provider Demographics
NPI:1073590998
Name:WIEST, JOHN WALTER (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WALTER
Last Name:WIEST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:847 NE 19TH AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2686
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:9155 SW BARNES RD STE 440
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6631
Practice Address - Country:US
Practice Address - Phone:503-935-8500
Practice Address - Fax:503-935-8505
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-30
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD144742086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR175216Medicaid
ORR109779Medicare ID - Type Unspecified
ORR109778Medicare ID - Type Unspecified
OR175216Medicaid