Provider Demographics
NPI:1073593927
Name:WIEST, DANIEL R (RPAC)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:R
Last Name:WIEST
Suffix:
Gender:M
Credentials:RPAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11835 RT 9W
Mailing Address - Street 2:
Mailing Address - City:WEST COXSACKIE
Mailing Address - State:NY
Mailing Address - Zip Code:12192-3605
Mailing Address - Country:US
Mailing Address - Phone:518-731-9000
Mailing Address - Fax:518-731-9119
Practice Address - Street 1:11835 RT 9W
Practice Address - Street 2:
Practice Address - City:WEST COXSACKIE
Practice Address - State:NY
Practice Address - Zip Code:12192-3605
Practice Address - Country:US
Practice Address - Phone:518-731-9000
Practice Address - Fax:518-731-9119
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0039611207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
275191OtherWELLCARE NY
NY4937930001OtherMEDICARE DME
DW05762L10OtherBLUE CROSS
10050348OtherCDPHP
000406870004OtherBLUE SHIELD NENY
10050348OtherCDPHP