Provider Demographics
NPI:1750354221
Name:WIECK, JOSEPH A (MD)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:A
Last Name:WIECK
Suffix:
Gender:M
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:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-0370
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:706-494-3008
Practice Address - Street 1:25 DOCTOR DRIVE
Practice Address - Street 2:MEDICAL PLAZA 2
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4520
Practice Address - Country:US
Practice Address - Phone:850-767-2455
Practice Address - Fax:850-767-2790
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME143674207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN193771OtherBCBS
TN3083053Medicaid
TN0922510009Medicare PIN
TN193771OtherBCBS
TN200022601Medicare PIN
TNF81010Medicare UPIN
TN3083053Medicaid