Provider Demographics
NPI:1538146147
Name:WIESLER, ETHAN RON (MD)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:RON
Last Name:WIESLER
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:PO BOX 344
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27102-0344
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:336-716-8018
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-716-2255
Practice Address - Fax:336-716-8018
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC96-00222207XS0106X
NC9600222207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
126FFOtherBCBS
NC2280373AOtherMEDCIARE
36195OtherPARTNERS
7122310OtherAETNA
NC89126FFMedicaid
98579OtherMEDCOST
200043944OtherRR MEDICARE
WV1850002000Medicaid
VA6402941Medicaid
VA6402941Medicaid
NC2280373AMedicare PIN