Provider Demographics
NPI:1932161643
Name:WIETERS, JERALD SCOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:JERALD
Middle Name:SCOTT
Last Name:WIETERS
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 840003
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0003
Mailing Address - Country:US
Mailing Address - Phone:254-215-9704
Mailing Address - Fax:
Practice Address - Street 1:2401 S 31ST ST
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76508-0001
Practice Address - Country:US
Practice Address - Phone:254-724-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6719207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1754236-02OtherCSHCN
TX1754236-01Medicaid
TX8S6321OtherBLUE SHIELD
TXP00269400OtherRR/MEDICARE
TX1754236-01Medicaid
TX8S6321OtherBLUE SHIELD