Provider Demographics
NPI:1306825047
Name:WIEST, GERALD VINCENT (DO)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:VINCENT
Last Name:WIEST
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HQ AFIA
Mailing Address - Street 2:9700 G AVE SE, BLDG 24499
Mailing Address - City:KIRTLAND AIR FORCE BASE
Mailing Address - State:NM
Mailing Address - Zip Code:87117-5522
Mailing Address - Country:US
Mailing Address - Phone:702-540-5808
Mailing Address - Fax:
Practice Address - Street 1:HQ AFIA 9700 G AVE.SE
Practice Address - Street 2:BLDG. 24499
Practice Address - City:KIRTLAND AIR FORCE BASE
Practice Address - State:NM
Practice Address - Zip Code:87117-5522
Practice Address - Country:US
Practice Address - Phone:508-246-2486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVD. O. 716207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine