Provider Demographics
NPI:1689770372
Name:VIETZKE, WESLEY MAUNDER (MD)
Entity Type:Individual
Prefix:DR
First Name:WESLEY
Middle Name:MAUNDER
Last Name:VIETZKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:15 W HAYCOCK POINT RD
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-5307
Mailing Address - Country:US
Mailing Address - Phone:203-488-4688
Mailing Address - Fax:203-488-9087
Practice Address - Street 1:15 W HAYCOCK POINT RD
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-5307
Practice Address - Country:US
Practice Address - Phone:203-488-4688
Practice Address - Fax:203-488-9087
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT013073207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E32385Medicare UPIN