Provider Demographics
NPI:1306846423
Name:WILEY, JENNIFER SUSAN (DO)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SUSAN
Last Name:WILEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:SUSAN
Other - Last Name:PYENTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:4 GLEN COVE DR STE 202
Mailing Address - Street 2:
Mailing Address - City:ROCKPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04856-4238
Mailing Address - Country:US
Mailing Address - Phone:207-301-5800
Mailing Address - Fax:207-301-5332
Practice Address - Street 1:4 GLEN COVE DR STE 202
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:ME
Practice Address - Zip Code:04856-4238
Practice Address - Country:US
Practice Address - Phone:207-301-5800
Practice Address - Fax:207-301-5332
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDO2092207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI563908911Medicaid
MI700Q262160OtherBCBSM
MI700H201530OtherBCBSM
MI700H270060OtherBCBSM
MIN71840054Medicare PIN
MIM71670172Medicare PIN
MI563908911Medicaid
MI700H270060OtherBCBSM