Provider Demographics
NPI:1780806141
Name:WIESE, LAURA ELIZABETH (OD)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:ELIZABETH
Last Name:WIESE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3104 CROSS BEND RD
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75023-5603
Mailing Address - Country:US
Mailing Address - Phone:972-596-3429
Mailing Address - Fax:972-596-3429
Practice Address - Street 1:1138 BELT LINE RD STE 230
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75040-1994
Practice Address - Country:US
Practice Address - Phone:972-495-3997
Practice Address - Fax:972-414-0912
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5470TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist