Provider Demographics
NPI:1942383096
Name:WIESE, KURT L (MD)
Entity Type:Individual
Prefix:
First Name:KURT
Middle Name:L
Last Name:WIESE
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 1:2900 N MILITARY TRL STE 243
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-6362
Mailing Address - Country:US
Mailing Address - Phone:561-496-1095
Mailing Address - Fax:561-948-4473
Practice Address - Street 1:2900 N MILITARY TRL STE 243
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-6362
Practice Address - Country:US
Practice Address - Phone:561-496-1095
Practice Address - Fax:561-948-4473
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0061675207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME0061675OtherMEDICAL LICENSE NUMBER