Provider Demographics
NPI:1821043399
Name:THEODORE A. WIZENBERG, M.D.,P.C.
Entity Type:Organization
Organization Name:THEODORE A. WIZENBERG, M.D.,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:A
Authorized Official - Last Name:WIZENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-661-9125
Mailing Address - Street 1:31151 WESTWOOD RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-1471
Mailing Address - Country:US
Mailing Address - Phone:248-661-9125
Mailing Address - Fax:
Practice Address - Street 1:23901 LAHSER RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-6035
Practice Address - Country:US
Practice Address - Phone:248-357-3360
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITW038081207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIA77757OtherHAP
MI113381OtherCARE CHOICE
MI1106338231OtherBCBS
MI200089OtherTOTAL HEALTH
MI0N95670Medicare ID - Type Unspecified
MI200089OtherTOTAL HEALTH