Provider Demographics
NPI:1770597726
Name:WIET, SUSAN MARIE (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MARIE
Last Name:WIET
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:850 E 300 S STE 1
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-2301
Mailing Address - Country:US
Mailing Address - Phone:385-429-9808
Mailing Address - Fax:844-838-8100
Practice Address - Street 1:160 S 1000 E STE 220
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1552
Practice Address - Country:US
Practice Address - Phone:978-743-9438
Practice Address - Fax:844-838-8100
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3711062084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT37110612001001OtherBLUE CROSS BLUE SHIELD
UT70927OtherPUBLIC EMPLOYEES HEALTH P
UT870663870SW2OtherEMIA