Provider Demographics
NPI:1578568093
Name:WIELAND, JEFFERY (DPM)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:
Last Name:WIELAND
Suffix:
Gender:M
Credentials:DPM
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 483
Mailing Address - Street 2:
Mailing Address - City:CHARDON
Mailing Address - State:OH
Mailing Address - Zip Code:44024-0483
Mailing Address - Country:US
Mailing Address - Phone:440-285-2666
Mailing Address - Fax:
Practice Address - Street 1:325 CENTER ST
Practice Address - Street 2:STE 1
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024
Practice Address - Country:US
Practice Address - Phone:440-285-2666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36-00-3359213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2426682Medicaid
OHU96615Medicare UPIN
OHWI4114511Medicare ID - Type Unspecified