Provider Demographics
NPI:1770525198
Name:WIESCHHAUS, MARTIN F (MD)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:F
Last Name:WIESCHHAUS
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 1:707 CEDAR ST STE 405
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2059
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:611 E DOUGLAS RD
Practice Address - Street 2:STE 407
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1464
Practice Address - Country:US
Practice Address - Phone:574-335-6500
Practice Address - Fax:574-335-0772
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036210A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100325860Medicaid
IN1102246243OtherANTHEM
INP01114840Medicare PIN
IND94945Medicare UPIN
IN738460RMedicare ID - Type Unspecified
ININ1133012Medicare PIN