Provider Demographics
NPI:1407814627
Name:WIESE, BARRY (DC)
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:
Last Name:WIESE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5471 DR MARTIN LUTHER KING DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63112-4265
Mailing Address - Country:US
Mailing Address - Phone:314-367-5820
Mailing Address - Fax:314-367-7010
Practice Address - Street 1:5471 DR MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63112-4265
Practice Address - Country:US
Practice Address - Phone:314-367-5820
Practice Address - Fax:314-367-7010
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014005327111N00000X
NY010976X111NS0005X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2014005327OtherMO LICENSE
NYC10976-1WOtherWORKERS COMP
NYU58074Medicare UPIN
NY010976XOtherNY STATE LICENSE
NY13-1916574OtherTAX ID
NY155343ANOtherPREFERRED CARE
NYP020010976OtherBLUE SHIELD
NYRA5162Medicare ID - Type Unspecified