Provider Demographics
NPI:1164472577
Name:WIESKOPF, BRAM (MD)
Entity Type:Individual
Prefix:
First Name:BRAM
Middle Name:
Last Name:WIESKOPF
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 1:1192 BUCKHEAD XING
Mailing Address - Street 2:SUITE E
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-4254
Mailing Address - Country:US
Mailing Address - Phone:678-494-4450
Mailing Address - Fax:678-494-6265
Practice Address - Street 1:1192 BUCKHEAD XING
Practice Address - Street 2:SUITE E
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-4254
Practice Address - Country:US
Practice Address - Phone:678-494-4450
Practice Address - Fax:678-494-6265
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA045136207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG98749Medicare UPIN