Provider Demographics
NPI:1376728287
Name:GREGORY J WIENER M D PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:GREGORY J WIENER M D PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:WIENER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-585-8883
Mailing Address - Street 1:353 CHURCH AVE STE A
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-3906
Mailing Address - Country:US
Mailing Address - Phone:619-585-8883
Mailing Address - Fax:
Practice Address - Street 1:353 CHURCH AVE STE A
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-3906
Practice Address - Country:US
Practice Address - Phone:619-585-8883
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-09
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41749261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW22034OtherMEDICARE GROUP PROVIDER
CA00A417490Medicaid
CA00A417490Medicaid