Provider Demographics
NPI:1255402491
Name:WIENKE, PETER G (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:G
Last Name:WIENKE
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 1:901 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-3127
Mailing Address - Country:US
Mailing Address - Phone:636-239-8090
Mailing Address - Fax:636-390-7385
Practice Address - Street 1:901 E 5TH ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-3127
Practice Address - Country:US
Practice Address - Phone:636-239-8090
Practice Address - Fax:636-390-7385
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8N11207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOE66092Medicare UPIN