Provider Demographics
NPI:1689994113
Name:WIESE, JONATHAN EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:EDWARD
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 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-6450
Mailing Address - Fax:414-805-6464
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226
Practice Address - Country:US
Practice Address - Phone:414-805-6450
Practice Address - Fax:414-805-6464
Is Sole Proprietor?:No
Enumeration Date:2010-06-07
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI56819-20207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1689994113Medicaid