Provider Demographics
NPI:1538137005
Name:WIESE, MICHAEL B (MD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:B
Last Name:WIESE
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 1:183 INTREPID LN
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13205-2548
Mailing Address - Country:US
Mailing Address - Phone:315-251-0401
Mailing Address - Fax:315-251-0405
Practice Address - Street 1:183 INTREPID LN
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13205-2548
Practice Address - Country:US
Practice Address - Phone:315-251-0401
Practice Address - Fax:315-251-0405
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY175162207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01499807Medicaid
NYF75277Medicare UPIN
NY01499807Medicaid