Provider Demographics
NPI:1205980422
Name:WIESENHUTTER, CRAIG W (MD)
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:W
Last Name:WIESENHUTTER
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 1:950 W IRONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2644
Mailing Address - Country:US
Mailing Address - Phone:208-765-5457
Mailing Address - Fax:208-765-6248
Practice Address - Street 1:950 W IRONWOOD DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2644
Practice Address - Country:US
Practice Address - Phone:208-765-5457
Practice Address - Fax:208-765-6248
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM4720207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000010005797OtherBLUE SHIELD
ID002074200Medicaid
47209OtherBLUE CROSS
1377319Medicare ID - Type Unspecified
B63633Medicare UPIN