Provider Demographics
NPI:1497741094
Name:WISSLER, MICHAEL G (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:WISSLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 KIDSPEACE DR
Mailing Address - Street 2:
Mailing Address - City:OREFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:18069-2044
Mailing Address - Country:US
Mailing Address - Phone:610-799-8853
Mailing Address - Fax:610-799-8001
Practice Address - Street 1:5300 KIDSPEACE DR
Practice Address - Street 2:KIDSPEACE NATIONAL CENTERS, INC.
Practice Address - City:OREFIELD
Practice Address - State:PA
Practice Address - Zip Code:18069-2044
Practice Address - Country:US
Practice Address - Phone:610-799-8853
Practice Address - Fax:610-799-8001
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA05010543L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102505900-0001Medicaid
PA037767SN4Medicare ID - Type Unspecified