Provider Demographics
NPI:1750321857
Name:WIENS, MICHAEL BRENT (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BRENT
Last Name:WIENS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 258884
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73125-8884
Mailing Address - Country:US
Mailing Address - Phone:405-231-3857
Mailing Address - Fax:405-272-7977
Practice Address - Street 1:3315 KETHLEY RD
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-9638
Practice Address - Country:US
Practice Address - Phone:405-273-5801
Practice Address - Fax:405-878-3794
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2016-11-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK19657208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100193970AMedicaid
OK100193970AMedicaid