Provider Demographics
NPI:1457434508
Name:WIETMARSCHEN, MICHAEL TODD (AT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:TODD
Last Name:WIETMARSCHEN
Suffix:
Gender:M
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5400 FRANTZ RD
Mailing Address - Street 2:STE 250
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-4144
Mailing Address - Country:US
Mailing Address - Phone:614-544-6382
Mailing Address - Fax:614-544-6370
Practice Address - Street 1:323 E TOWN ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-4767
Practice Address - Country:US
Practice Address - Phone:614-461-8714
Practice Address - Fax:614-461-9155
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OHAT0028042255A2300X
OH50.003003363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer