Provider Demographics
NPI:1669461000
Name:WIENECKE, ROBERT JEROME (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:JEROME
Last Name:WIENECKE
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14100 PARKWAY COMMONS DR STE 100
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-6036
Mailing Address - Country:US
Mailing Address - Phone:405-748-3300
Mailing Address - Fax:405-748-2920
Practice Address - Street 1:14100 PARKWAY COMMONS DR STE 100
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-6036
Practice Address - Country:US
Practice Address - Phone:405-748-3300
Practice Address - Fax:405-748-2920
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK21277174400000X, 207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200043320AMedicaid
243503901Medicare PIN
OK200043320AMedicaid