Provider Demographics
NPI:1235448184
Name:SCOTT L WIESEN MD LLC
Entity Type:Organization
Organization Name:SCOTT L WIESEN MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:L
Authorized Official - Last Name:WIESEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-775-4444
Mailing Address - Street 1:625 9TH ST N
Mailing Address - Street 2:SUITE 304
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34102-8143
Mailing Address - Country:US
Mailing Address - Phone:239-775-4444
Mailing Address - Fax:239-775-4445
Practice Address - Street 1:625 TAMIAMI TRL N
Practice Address - Street 2:SUITE 304
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-8143
Practice Address - Country:US
Practice Address - Phone:239-775-4444
Practice Address - Fax:239-775-4445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-27
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME53124207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty