Provider Demographics
NPI:1831187087
Name:WIECEK, RICHARD M (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:M
Last Name:WIECEK
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:PO BOX 378
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44871-0378
Mailing Address - Country:US
Mailing Address - Phone:419-609-1112
Mailing Address - Fax:419-609-1123
Practice Address - Street 1:1479 N RIVER RD STE 120
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-9760
Practice Address - Country:US
Practice Address - Phone:419-559-2814
Practice Address - Fax:419-355-8490
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35084364208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2491941Medicaid
OH32012600600OtherBWC
OHI09988Medicare UPIN