Provider Demographics
NPI:1790865004
Name:WEISE, WOLFGANG JOHANNES (MD)
Entity type:Individual
Prefix:DR
First Name:WOLFGANG
Middle Name:JOHANNES
Last Name:WEISE
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 1:136 N PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-3347
Mailing Address - Country:US
Mailing Address - Phone:802-660-4910
Mailing Address - Fax:
Practice Address - Street 1:1 S PROSPECT ST
Practice Address - Street 2:2318 REHAB.BLDG, UHC
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-3456
Practice Address - Country:US
Practice Address - Phone:802-847-3572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYE01434028Medicaid
VTOVN0717Medicaid
NYE01434028Medicaid
VTOVN0717Medicaid