Provider Demographics
NPI:1386626497
Name:WIESNER, ELISE R (MD)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:R
Last Name:WIESNER
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:PO BOX 1330
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73070-1330
Mailing Address - Country:US
Mailing Address - Phone:405-307-6630
Mailing Address - Fax:405-307-6660
Practice Address - Street 1:500 E ROBINSON ST STE 2400
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-6684
Practice Address - Country:US
Practice Address - Phone:405-515-0380
Practice Address - Fax:405-307-5632
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18219207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100826940AMedicaid