Provider Demographics
NPI:1841342854
Name:WIESNER, PAUL D (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:D
Last Name:WIESNER
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 1:1800 E. PAVILION PLACE
Mailing Address - Street 2:SUITE B
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401
Mailing Address - Country:US
Mailing Address - Phone:970-249-1210
Mailing Address - Fax:970-249-3057
Practice Address - Street 1:1800 E. PAVILION PLACE
Practice Address - Street 2:SUITE B
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401
Practice Address - Country:US
Practice Address - Phone:970-249-1210
Practice Address - Fax:970-249-3057
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO25545207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
45289OtherBLUECROSS BLUE SHIELD
CO01255454Medicaid
840851676003OtherROCKY MOUNTAIN HEALTH PLA
0754950001OtherDME REGION C PALMETTO GBA
180002594OtherRAILROAD MEDICARE
C98634Medicare PIN
D24652Medicare UPIN