Provider Demographics
NPI:1811099534
Name:WIENER, GREGORY J (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:J
Last Name:WIENER
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 1:353A CHURCH AVE
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-3906
Mailing Address - Country:US
Mailing Address - Phone:619-585-8883
Mailing Address - Fax:619-585-8892
Practice Address - Street 1:353 CHURCH AVE # A
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-3906
Practice Address - Country:US
Practice Address - Phone:619-585-8883
Practice Address - Fax:619-585-8892
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41749207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A417490Medicaid
CA00A417490Medicaid
CAA41749Medicare PIN