Provider Demographics
NPI:1679548424
Name:WIEBER, DAVID J (ATC,MTC,LPT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:WIEBER
Suffix:
Gender:M
Credentials:ATC,MTC,LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1961 CARDINAL LN
Mailing Address - Street 2:STE A
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021-4354
Mailing Address - Country:US
Mailing Address - Phone:507-645-2235
Mailing Address - Fax:
Practice Address - Street 1:328 HERITAGE PL
Practice Address - Street 2:SUITE B
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-5251
Practice Address - Country:US
Practice Address - Phone:507-333-2986
Practice Address - Fax:507-333-2918
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4148225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN644723600Medicaid
MN650000084Medicare ID - Type Unspecified