Provider Demographics
NPI:1417931296
Name:WIESE, JULIE A (MD)
Entity Type:Individual
Prefix:DR
First Name:JULIE
Middle Name:A
Last Name:WIESE
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 1:934 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-7135
Mailing Address - Country:US
Mailing Address - Phone:801-773-7060
Mailing Address - Fax:
Practice Address - Street 1:934 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-7135
Practice Address - Country:US
Practice Address - Phone:801-773-7060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT30902712052084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT292740OtherDESERET MUTUAL
UT346475OtherUNKNOWN CARRIER
UT942938348W11OtherEDUCATORS MUTUAL
UT10700772D103OtherINTRMTN. HEALTH CARE