Provider Demographics
NPI:1215032149
Name:WIERSCHEM, MICHAEL G (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:WIERSCHEM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 911220
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75391-1230
Mailing Address - Country:US
Mailing Address - Phone:972-997-8000
Mailing Address - Fax:972-234-0813
Practice Address - Street 1:5425 W SPRING CREEK PKWY
Practice Address - Street 2:SUITE 150
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024-4236
Practice Address - Country:US
Practice Address - Phone:972-403-5425
Practice Address - Fax:214-501-1252
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXK7120208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX104042005Medicaid
TX104042004Medicaid
TXP01843066OtherRAILROAD
TX751531693OtherTAX ID #
8B6833OtherMEDICARE PTAN
TX535738YKYCMedicare PIN