Provider Demographics
NPI:1740265404
Name:WIESENFELD, MARTIN (MD, FACP)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:WIESENFELD
Suffix:
Gender:M
Credentials:MD, FACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 10TH ST SE
Mailing Address - Street 2:HPCC 3RD FLOOR
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52403-1251
Mailing Address - Country:US
Mailing Address - Phone:319-363-8303
Mailing Address - Fax:319-364-4659
Practice Address - Street 1:701 10TH ST SE
Practice Address - Street 2:HPCC 3RD FLOOR
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52403-1251
Practice Address - Country:US
Practice Address - Phone:319-363-8303
Practice Address - Fax:319-364-4659
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA20679207RX0202X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA110045771OtherRAILROAD MEDICARE
IA0163055Medicaid
IA16305OtherWELLMARK BC/BS
IA110045771OtherRAILROAD MEDICARE
IAA01466Medicare UPIN