Healthcare Provider Details

I. General information

NPI: 1396700217
Provider Name (Legal Business Name): VIRGINIA L MAHER WIESE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 05/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 SAYBROOK ROAD
ESSEX CT
06426-1401
US

IV. Provider business mailing address

20 SAYBROOK ROAD
ESSEX CT
06426-1401
US

V. Phone/Fax

Practice location:
  • Phone: 860-767-9998
  • Fax: 860-767-9161
Mailing address:
  • Phone: 860-767-9998
  • Fax: 860-767-9161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number032989
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: