Provider Demographics
NPI:1760465686
Name:WIENS, JERYL (MD)
Entity Type:Individual
Prefix:
First Name:JERYL
Middle Name:
Last Name:WIENS
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 1:1630 E HERNDON AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3305
Mailing Address - Country:US
Mailing Address - Phone:559-256-5200
Mailing Address - Fax:559-256-5376
Practice Address - Street 1:1630 E HERNDON AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3305
Practice Address - Country:US
Practice Address - Phone:559-256-5200
Practice Address - Fax:559-256-5376
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG50505208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA250014100OtherRAILROAD MEDICARE
CA0170702OtherSTATE OF WASHINGTON
CAA51705Medicare UPIN
CA0170702OtherSTATE OF WASHINGTON
CA250014100OtherRAILROAD MEDICARE