Provider Demographics
NPI:1609919497
Name:WIESENBERGER, EILEEN S (DO)
Entity Type:Individual
Prefix:DR
First Name:EILEEN
Middle Name:S
Last Name:WIESENBERGER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6190 GEORGETOWN BLVD
Mailing Address - Street 2:
Mailing Address - City:ELDERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21784-6460
Mailing Address - Country:US
Mailing Address - Phone:410-552-5050
Mailing Address - Fax:
Practice Address - Street 1:6190 GEORGETOWN BLVD
Practice Address - Street 2:
Practice Address - City:ELDERSBURG
Practice Address - State:MD
Practice Address - Zip Code:21784-6460
Practice Address - Country:US
Practice Address - Phone:410-552-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2012-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDP18479207R00000X
FLOS 10334207R00000X
MDH0073247207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000608200Medicaid
FL000608200Medicaid