Provider Demographics
NPI:1184945297
Name:WIESMAN, KATHRYN DENISE (MD)
Entity type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:DENISE
Last Name:WIESMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KATHRYN
Other - Middle Name:WIESMAN
Other - Last Name:CECIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:7777 FOREST LN STE C135
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-6825
Mailing Address - Country:US
Mailing Address - Phone:972-347-4783
Mailing Address - Fax:
Practice Address - Street 1:3533 S ALAMEDA ST
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-1721
Practice Address - Country:US
Practice Address - Phone:361-694-5057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-13
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015010246207XP3100X
TXQ8221207XP3100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX362392802Medicaid
TX362392802Medicaid