Provider Demographics
NPI:1851322549
Name:WIERSEMA, DAVID A (DO)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:WIERSEMA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4701 TOWNE CENTRE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48604-2800
Mailing Address - Country:US
Mailing Address - Phone:989-797-4610
Mailing Address - Fax:989-797-4612
Practice Address - Street 1:4701 TOWNE CENTRE RD STE 102
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-2800
Practice Address - Country:US
Practice Address - Phone:989-797-4610
Practice Address - Fax:989-797-4612
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDW012159208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4247329 11Medicaid
MI0N17260Medicare ID - Type Unspecified
MIG59815Medicare UPIN