Provider Demographics
NPI:1326020256
Name:WIATER, JEROME P (MD)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:P
Last Name:WIATER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JEROME
Other - Middle Name:PATRICK
Other - Last Name:WIATER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:17877 W 14 MILE RD
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-3127
Mailing Address - Country:US
Mailing Address - Phone:248-644-3920
Mailing Address - Fax:248-644-2569
Practice Address - Street 1:17877 W 14 MILE RD
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:MI
Practice Address - Zip Code:48025-3127
Practice Address - Country:US
Practice Address - Phone:248-644-3920
Practice Address - Fax:248-644-2569
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2016-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301028424207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1358914Medicaid
MI0630774Medicare ID - Type Unspecified
MI1358914Medicaid