Provider Demographics
NPI:1306845987
Name:WIESEL, JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:WIESEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4401 FRANCIS LEWIS BLVD
Mailing Address - Street 2:SUITE L3A
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-3028
Mailing Address - Country:US
Mailing Address - Phone:718-717-0238
Mailing Address - Fax:718-717-0265
Practice Address - Street 1:142-42 BOOTH MEMORIAL AVENUE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-5342
Practice Address - Country:US
Practice Address - Phone:718-353-4004
Practice Address - Fax:718-353-4240
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY150744207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01076728Medicaid
B20300Medicare UPIN
NY01076728Medicaid
NYA400087126Medicare PIN