Provider Demographics
NPI:1952475444
Name:WIENER, RICHARD (O,D)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:WIENER
Suffix:
Gender:M
Credentials:O,D
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 427
Mailing Address - Street 2:
Mailing Address - City:CONNERSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47331-0427
Mailing Address - Country:US
Mailing Address - Phone:765-825-4127
Mailing Address - Fax:765-827-6577
Practice Address - Street 1:124 E 6TH ST
Practice Address - Street 2:
Practice Address - City:CONNERSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47331-2025
Practice Address - Country:US
Practice Address - Phone:765-825-4127
Practice Address - Fax:765-827-6577
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2009-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ININ1652152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100114620AMedicaid
IN260070AOtherMEDICARE-UNSPECIFIED PTAN
IN260070AOtherMEDICARE-UNSPECIFIED PTAN
IN100114620AMedicaid