Provider Demographics
NPI:1760464911
Name:WIET, RICHARD J (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:J
Last Name:WIET
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 1:11 SALT CREEK LN
Mailing Address - Street 2:SUITE 101
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-2990
Mailing Address - Country:US
Mailing Address - Phone:630-789-3110
Mailing Address - Fax:630-789-3137
Practice Address - Street 1:11 SALT CREEK LN
Practice Address - Street 2:SUITE 101
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-2990
Practice Address - Country:US
Practice Address - Phone:630-789-3110
Practice Address - Fax:630-789-3137
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-047459207YX0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & Neurotology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL403270OtherMEDICARE GROUP PTAN
IL36047459Medicaid
IL400280OtherGROUP MEDICARE PTAN
ILL93442Medicare ID - Type Unspecified
IL36047459Medicaid