Provider Demographics
NPI:1639141054
Name:WIEN, FREDERIC ELLIOT (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDERIC
Middle Name:ELLIOT
Last Name:WIEN
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 1:680 BROADWAY STE 114
Mailing Address - Street 2:
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07514-1526
Mailing Address - Country:US
Mailing Address - Phone:973-742-2228
Mailing Address - Fax:973-742-2297
Practice Address - Street 1:680 BROADWAY STE 114
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07514-1526
Practice Address - Country:US
Practice Address - Phone:973-742-2228
Practice Address - Fax:973-742-2297
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-02
Last Update Date:2023-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNJ36940207R00000X, 207RG0100X
NY140230207RG0100X
NJ25MA03694000207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0989207Medicaid
NJ901223Medicare ID - Type Unspecified
NJ0989207Medicaid