Provider Demographics
NPI:1629174800
Name:WIEBENGA, JEANNE ELIZABETH (MD)
Entity Type:Individual
Prefix:DR
First Name:JEANNE
Middle Name:ELIZABETH
Last Name:WIEBENGA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 LOWELL AVE
Mailing Address - Street 2:P. O. BOX 64
Mailing Address - City:CHAUTAUQUA
Mailing Address - State:NY
Mailing Address - Zip Code:14722-0064
Mailing Address - Country:US
Mailing Address - Phone:716-357-9604
Mailing Address - Fax:
Practice Address - Street 1:22 LOWELL AVE
Practice Address - Street 2:
Practice Address - City:CHAUTAUQUA
Practice Address - State:NY
Practice Address - Zip Code:14722-0064
Practice Address - Country:US
Practice Address - Phone:716-357-9604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY164516207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBB9065Medicare ID - Type Unspecified
NYF41678Medicare UPIN