Provider Demographics
NPI:1710198957
Name:WIESMAN, ALLISON JANE
Entity Type:Individual
Prefix:DR
First Name:ALLISON
Middle Name:JANE
Last Name:WIESMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 W MCKENZIE RD
Mailing Address - Street 2:SUITE H
Mailing Address - City:GREENFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46140-3084
Mailing Address - Country:US
Mailing Address - Phone:317-462-2335
Mailing Address - Fax:317-462-2069
Practice Address - Street 1:156 W MUSKEGON DR
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:IN
Practice Address - Zip Code:46140-3069
Practice Address - Country:US
Practice Address - Phone:317-468-6270
Practice Address - Fax:317-468-6268
Is Sole Proprietor?:No
Enumeration Date:2007-05-26
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11013113A390200000X
IN01066799A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200945360Medicaid
IN000000617054OtherANTHEM PIN NUMBER
IN200311740EOtherMEDICAID GROUP NUMBER
IN208000000XOtherTAXONOMY CODE
IN200945360Medicaid