Provider Demographics
NPI:1225096969
Name:WIERSIG, JEREMY NYLE (MD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:NYLE
Last Name:WIERSIG
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:PO BOX 1888
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75403
Mailing Address - Country:US
Mailing Address - Phone:800-945-2455
Mailing Address - Fax:903-453-2541
Practice Address - Street 1:18802 MEISNER DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258
Practice Address - Country:US
Practice Address - Phone:210-572-2222
Practice Address - Fax:210-249-2177
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH55002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX136889611Medicaid
TX8F0590Medicare PIN
TX136889611Medicaid
E38861Medicare UPIN