Provider Demographics
NPI:1164581450
Name:WIETHOFF, RICHARD ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:ALLEN
Last Name:WIETHOFF
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 1:1613 BELL FORD DR
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:IN
Mailing Address - Zip Code:47274
Mailing Address - Country:US
Mailing Address - Phone:812-522-2177
Mailing Address - Fax:812-522-4069
Practice Address - Street 1:225 S PINE ST SUITE 310
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274
Practice Address - Country:US
Practice Address - Phone:812-522-2177
Practice Address - Fax:812-522-4069
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01024324208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN00000084530OtherANTHEM
IN20000020AMedicaid
IN20000020AMedicaid
IN381610AMedicare ID - Type Unspecified