Provider Demographics
NPI:1255368106
Name:WIETERS, THOMAS R (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:R
Last Name:WIETERS
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 1:3070 N HIGHWAY 17
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-9300
Mailing Address - Country:US
Mailing Address - Phone:843-881-8346
Mailing Address - Fax:843-284-4093
Practice Address - Street 1:3070 N HIGHWAY 17
Practice Address - Street 2:SUITE 202
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466-9300
Practice Address - Country:US
Practice Address - Phone:843-881-8346
Practice Address - Fax:843-284-4093
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC104862086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1518149350OtherNPI
SC1518149350OtherNPI
SCB91932Medicare UPIN