Provider Demographics
NPI:1174274856
Name:JONATHAN WIESEN MD PLLC
Entity Type:Organization
Organization Name:JONATHAN WIESEN MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WIESEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-564-4890
Mailing Address - Street 1:1075 STEPHENSON AVE STE D2
Mailing Address - Street 2:
Mailing Address - City:OCEANPORT
Mailing Address - State:NJ
Mailing Address - Zip Code:07757-1242
Mailing Address - Country:US
Mailing Address - Phone:833-223-2266
Mailing Address - Fax:732-329-2322
Practice Address - Street 1:668 N FOREST DR
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-2047
Practice Address - Country:US
Practice Address - Phone:201-564-4890
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-13
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty