Provider Demographics
NPI:1629142567
Name:WIEBER, MICHAEL A (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:WIEBER
Suffix:
Gender:M
Credentials:OD
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 540
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MN
Mailing Address - Zip Code:55362-0540
Mailing Address - Country:US
Mailing Address - Phone:763-295-5292
Mailing Address - Fax:763-271-4219
Practice Address - Street 1:261 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-0540
Practice Address - Country:US
Practice Address - Phone:763-295-5292
Practice Address - Fax:763-271-4219
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1708152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0157480001Medicare NSC
MNT66290Medicare UPIN