Provider Demographics
NPI:1235196866
Name:WIESE, EDWARD A (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:A
Last Name:WIESE
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 1:2422 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-4985
Mailing Address - Country:US
Mailing Address - Phone:440-992-4422
Mailing Address - Fax:440-997-6507
Practice Address - Street 1:2422 LAKE AVE
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-4985
Practice Address - Country:US
Practice Address - Phone:440-992-4422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35069100207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0386014Medicaid
OHG51293Medicare UPIN
OH0386014Medicaid