Provider Demographics
NPI:1477555829
Name:WIETSCHNER, MARC E (MD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:E
Last Name:WIETSCHNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:342 JERICHO TPKE
Mailing Address - Street 2:
Mailing Address - City:FLORAL PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11001-2108
Mailing Address - Country:US
Mailing Address - Phone:516-354-2020
Mailing Address - Fax:516-354-0400
Practice Address - Street 1:342 JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:FLORAL PARK
Practice Address - State:NY
Practice Address - Zip Code:11001-2108
Practice Address - Country:US
Practice Address - Phone:516-354-2020
Practice Address - Fax:516-354-0400
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY186943207W00000X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY78T58XZRQ1Medicare UPIN
NY02198Medicare ID - Type Unspecified
NYG29684Medicare UPIN