Provider Demographics
NPI:1346541943
Name:WIESENFELD, STEPHEN L
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:L
Last Name:WIESENFELD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3102 SHELL AVE
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79705-8237
Mailing Address - Country:US
Mailing Address - Phone:432-694-3056
Mailing Address - Fax:432-697-3342
Practice Address - Street 1:3102 SHELL AVE
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79705-8237
Practice Address - Country:US
Practice Address - Phone:432-694-3056
Practice Address - Fax:432-697-3342
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-12
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE8231207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine