Provider Demographics
NPI:1952474561
Name:WIESE, JON D (MD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:D
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 1:521 W STATE ROAD 434
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-5166
Mailing Address - Country:US
Mailing Address - Phone:407-767-5808
Mailing Address - Fax:407-767-5892
Practice Address - Street 1:521 W STATE ROAD 434
Practice Address - Street 2:SUITE 301
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-5166
Practice Address - Country:US
Practice Address - Phone:407-767-5808
Practice Address - Fax:407-767-5892
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME54060208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME54060OtherMEDICAL LICENSE
FL049597200Medicaid
FLME54060OtherMEDICAL LICENSE
FLA02844Medicare UPIN