Provider Demographics
NPI:1396700217
Name:MAHER WIESE, VIRGINIA L (MD)
Entity type:Individual
Prefix:DR
First Name:VIRGINIA
Middle Name:L
Last Name:MAHER WIESE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 SAYBROOK ROAD
Mailing Address - Street 2:
Mailing Address - City:ESSEX
Mailing Address - State:CT
Mailing Address - Zip Code:06426-1401
Mailing Address - Country:US
Mailing Address - Phone:860-767-9998
Mailing Address - Fax:860-767-9161
Practice Address - Street 1:20 SAYBROOK ROAD
Practice Address - Street 2:
Practice Address - City:ESSEX
Practice Address - State:CT
Practice Address - Zip Code:06426-1401
Practice Address - Country:US
Practice Address - Phone:860-767-9998
Practice Address - Fax:860-767-9161
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-20
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT032989207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001329897Medicaid
F55414Medicare UPIN
CT001329897Medicaid