Provider Demographics
NPI:1437103678
Name:WIESEN, ROBERT S (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:S
Last Name:WIESEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 PORT IMPERIAL
Mailing Address - Street 2:
Mailing Address - City:WEST NEW YORK
Mailing Address - State:NJ
Mailing Address - Zip Code:07093-8302
Mailing Address - Country:US
Mailing Address - Phone:201-601-0772
Mailing Address - Fax:908-231-1612
Practice Address - Street 1:286 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08876-3006
Practice Address - Country:US
Practice Address - Phone:908-231-1999
Practice Address - Fax:908-231-1612
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07943500207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology