Provider Demographics
NPI:1770860165
Name:WIESSNER, DANIEL JAMES (OD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:JAMES
Last Name:WIESSNER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 E ALDER ST
Mailing Address - Street 2:STE 1
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-2073
Mailing Address - Country:US
Mailing Address - Phone:509-529-9660
Mailing Address - Fax:
Practice Address - Street 1:614 E ALDER ST
Practice Address - Street 2:STE 1
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2073
Practice Address - Country:US
Practice Address - Phone:509-529-9660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-14
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60497198152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist