Provider Demographics
NPI:1669450557
Name:WIETECHA, KEVIN GERARD (DO)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:GERARD
Last Name:WIETECHA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4634 HILLS AND DALES RD NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-1510
Mailing Address - Country:US
Mailing Address - Phone:330-477-0255
Mailing Address - Fax:330-477-7266
Practice Address - Street 1:4634 HILLS AND DALES RD NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-1510
Practice Address - Country:US
Practice Address - Phone:330-477-0255
Practice Address - Fax:330-477-7266
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-00-6364W207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0247781Medicaid
OHWI0805152Medicare ID - Type UnspecifiedMEDICARE PROVIDER
OH0247781Medicaid