Provider Demographics
NPI:1659470250
Name:WIESE, KURT ALAN (MD)
Entity Type:Individual
Prefix:
First Name:KURT
Middle Name:ALAN
Last Name:WIESE
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 1:401 WALL ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-2521
Mailing Address - Country:US
Mailing Address - Phone:219-462-7773
Mailing Address - Fax:219-531-5988
Practice Address - Street 1:401 WALL ST
Practice Address - Street 2:SUITE B
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2521
Practice Address - Country:US
Practice Address - Phone:219-462-7773
Practice Address - Fax:219-531-5988
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040290A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100351680BMedicaid
IN90000628OtherIL BC/BS PROVIDER #
IN00000091658OtherANTHEM
INF28037Medicare UPIN
IN100351680BMedicaid