Provider Demographics
NPI:1346582764
Name:WIESNER, ERIC P (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:P
Last Name:WIESNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2643 PATTERSON RD
Mailing Address - Street 2:SUITE 503
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81506-1937
Mailing Address - Country:US
Mailing Address - Phone:970-245-2400
Mailing Address - Fax:970-242-9092
Practice Address - Street 1:100 TESSITORE CT
Practice Address - Street 2:SUITE B
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-5689
Practice Address - Country:US
Practice Address - Phone:970-787-4710
Practice Address - Fax:970-615-7007
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-24
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
390200000X
CODR.0062163208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000175731Medicaid