Provider Demographics
NPI:1245799071
Name:WIETECHA, DELIA ANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:DELIA
Middle Name:ANNE
Last Name:WIETECHA
Suffix:
Gender:F
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 26067
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84126-0067
Mailing Address - Country:US
Mailing Address - Phone:239-624-0400
Mailing Address - Fax:239-624-0401
Practice Address - Street 1:1845 VETERANS PARK DR STE 210
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-0493
Practice Address - Country:US
Practice Address - Phone:239-624-0530
Practice Address - Fax:239-624-0451
Is Sole Proprietor?:No
Enumeration Date:2019-03-19
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME156640207R00000X
FL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLXAFSBOtherFL BLUE
FL114801800Medicaid