Provider Demographics
NPI:1619402401
Name:WIESE, BENJAMIN MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:MICHAEL
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 1:1130 W MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-5209
Mailing Address - Country:US
Mailing Address - Phone:317-274-8282
Mailing Address - Fax:
Practice Address - Street 1:1500 S 48TH ST STE 800
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-1200
Practice Address - Country:US
Practice Address - Phone:402-483-8600
Practice Address - Fax:402-483-8689
Is Sole Proprietor?:No
Enumeration Date:2017-04-29
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01083924A207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine