Provider Demographics
NPI:1598799777
Name:WIESE, DEAN S (MD)
Entity Type:Individual
Prefix:DR
First Name:DEAN
Middle Name:S
Last Name:WIESE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1401 MARVIN RD NE
Mailing Address - Street 2:SUITE 307 PMB 266
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-5709
Mailing Address - Country:US
Mailing Address - Phone:360-491-5055
Mailing Address - Fax:360-491-5890
Practice Address - Street 1:403 BLACK HILLS LN SW STE A
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-8600
Practice Address - Country:US
Practice Address - Phone:360-705-0421
Practice Address - Fax:360-705-0493
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00030693207QA0505X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5007947OtherGROUP HEALTH
WAMD00030693OtherWA STATE LICENSE
WA1810019Medicaid
WA44789OtherL&I WORKERS COMP
WA953646046OtherTAX ID
WAWI0066OtherBLUE CROSS/BLUE SHIELD
WAMD00030693OtherWA STATE LICENSE
WA953646046OtherTAX ID
WAWI0066OtherBLUE CROSS/BLUE SHIELD