Provider Demographics
NPI:1770574014
Name:WEIN, RICHARD JOEL (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:JOEL
Last Name:WEIN
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 1:3625 PARK PL W
Mailing Address - Street 2:STE 100
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-3561
Mailing Address - Country:US
Mailing Address - Phone:574-232-5963
Mailing Address - Fax:574-287-7988
Practice Address - Street 1:3625 PARK PL W
Practice Address - Street 2:STE 100
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3561
Practice Address - Country:US
Practice Address - Phone:574-232-5963
Practice Address - Fax:574-287-7988
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-04
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01034947207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100090000AMedicaid
IN000000086629OtherBLUE CROSS BLUE SHIELD
IN000000086629OtherBLUE CROSS BLUE SHIELD
C24541Medicare UPIN
IN100090000AMedicaid