Provider Demographics
NPI:1811030695
Name:WIESENBERGER, SCOTT J (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:J
Last Name:WIESENBERGER
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 1:14907 MICHELE DR
Mailing Address - Street 2:
Mailing Address - City:GLENELG
Mailing Address - State:MD
Mailing Address - Zip Code:21737-9419
Mailing Address - Country:US
Mailing Address - Phone:954-594-4950
Mailing Address - Fax:
Practice Address - Street 1:4330 E WEST HWY
Practice Address - Street 2:SUITE 1100
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-4408
Practice Address - Country:US
Practice Address - Phone:301-986-8010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD038866207L00000X
VA0101247880207L00000X
MDD0070972207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology