Provider Demographics
NPI:1619901022
Name:WIESENTHAL, NORMAN (MD)
Entity Type:Individual
Prefix:
First Name:NORMAN
Middle Name:
Last Name:WIESENTHAL
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 1:3860 SAINT JAMES CT
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33434-3368
Mailing Address - Country:US
Mailing Address - Phone:954-655-4815
Mailing Address - Fax:
Practice Address - Street 1:3860 SAINT JAMES CT
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33434-3368
Practice Address - Country:US
Practice Address - Phone:954-655-4815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME30475207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL93444Medicare PIN
E12066Medicare UPIN