Provider Demographics
NPI:1316011083
Name:WIELER, LISA MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:MARIE
Last Name:WIELER
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 1:1100 MONTEREY ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-3102
Mailing Address - Country:US
Mailing Address - Phone:805-542-9700
Mailing Address - Fax:805-542-0584
Practice Address - Street 1:1100 MONTEREY ST
Practice Address - Street 2:SUITE 210
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-3102
Practice Address - Country:US
Practice Address - Phone:805-542-9700
Practice Address - Fax:805-542-0584
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG469862085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACH9716OtherCHAMPUS
CAG46986OtherLICENSE
CAP00138584OtherRAILROAD MEDICARE
CA00G19230Medicaid
CA00G19230Medicaid
CAA92694Medicare UPIN