Provider Demographics
NPI:1306826946
Name:WIESER, MICHAEL J (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:WIESER
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 1:801 MEDICAL DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45804-4099
Mailing Address - Country:US
Mailing Address - Phone:419-222-6622
Mailing Address - Fax:419-224-0015
Practice Address - Street 1:801 MEDICAL DR
Practice Address - Street 2:SUITE A
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-4099
Practice Address - Country:US
Practice Address - Phone:419-222-6622
Practice Address - Fax:419-224-0015
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35051495-W207X00000X
OH35.051495207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0704705Medicaid
OH000000020356OtherANTHEM
OH0614294Medicare PIN
A17384Medicare UPIN