Provider Demographics
NPI:1639158678
Name:WIETING, RICHARD JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:JOHN
Last Name:WIETING
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:38 ROLLING RD
Mailing Address - Street 2:
Mailing Address - City:MILLER PLACE
Mailing Address - State:NY
Mailing Address - Zip Code:11764-2217
Mailing Address - Country:US
Mailing Address - Phone:631-331-0633
Mailing Address - Fax:
Practice Address - Street 1:116 TERRYVILLE RD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1329
Practice Address - Country:US
Practice Address - Phone:631-928-2002
Practice Address - Fax:631-928-4934
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY225618207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02313720Medicaid
NY02313720Medicaid
NYH74652Medicare UPIN