Provider Demographics
NPI:1245225721
Name:WIELAND, WILLIAM K (OD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:K
Last Name:WIELAND
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8801 HORIZON BLVD NE
Mailing Address - Street 2:SUITE 360
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-1533
Mailing Address - Country:US
Mailing Address - Phone:505-828-4923
Mailing Address - Fax:505-213-0103
Practice Address - Street 1:806 DR MARTIN LUTHER KING JR AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-3657
Practice Address - Country:US
Practice Address - Phone:505-842-6575
Practice Address - Fax:505-764-8796
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM191152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM02P032OtherBC BS OF NM
NMP00156992OtherRRB MEDICARE RAILROAD
AZ881400Medicaid
NMP7354Medicaid
NMNM02P032OtherBC BS OF NM
NM341425505Medicare ID - Type Unspecified