Provider Demographics
NPI:1538110101
Name:WIESERT, KENNETH NIEL (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:NIEL
Last Name:WIESERT
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 1:4412 RADNOR RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46226-2150
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5868 E 71ST ST
Practice Address - Street 2:#123
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-4002
Practice Address - Country:US
Practice Address - Phone:317-885-2334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01026404A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100189000Medicaid
INB28293Medicare UPIN
IN945350DMedicare ID - Type Unspecified