Provider Demographics
NPI:1710921564
Name:WIESE, CRISTINA SUSANA (MD)
Entity Type:Individual
Prefix:
First Name:CRISTINA
Middle Name:SUSANA
Last Name:WIESE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5730 GREY ROCK RD
Mailing Address - Street 2:
Mailing Address - City:AGOURA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91301-4442
Mailing Address - Country:US
Mailing Address - Phone:805-557-0452
Mailing Address - Fax:805-557-0471
Practice Address - Street 1:325 ROLLING OAKS DR
Practice Address - Street 2:SUITE 100
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91361-1201
Practice Address - Country:US
Practice Address - Phone:805-557-0452
Practice Address - Fax:805-557-0471
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA91425207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine