Provider Demographics
NPI:1164733440
Name:WIEBE, ERICA DAWN (MD)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:DAWN
Last Name:WIEBE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W. PARK ST.
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-383-6941
Mailing Address - Fax:
Practice Address - Street 1:1701 W. CURTIS RD.
Practice Address - Street 2:PEDIATRICS
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-9678
Practice Address - Country:US
Practice Address - Phone:217-365-6202
Practice Address - Fax:217-326-0188
Is Sole Proprietor?:No
Enumeration Date:2010-07-01
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010017748207K00000X
IL0361410172080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology