Provider Demographics
NPI:1720373673
Name:WIESE, BRANDON J (DO)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:J
Last Name:WIESE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 E BATTLEFIELD ST STE 124
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5208
Mailing Address - Country:US
Mailing Address - Phone:417-986-1289
Mailing Address - Fax:
Practice Address - Street 1:900 E BATTLEFIELD ST STE 124
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5208
Practice Address - Country:US
Practice Address - Phone:417-986-1289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-17
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP8564207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine