Healthcare Provider Details

I. General information

NPI: 1740265404
Provider Name (Legal Business Name): MARTIN WIESENFELD M.D., F.A.C.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 04/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 10TH ST SE HPCC 3RD FLOOR
CEDAR RAPIDS IA
52403-1251
US

IV. Provider business mailing address

701 10TH ST SE HPCC 3RD FLOOR
CEDAR RAPIDS IA
52403-1251
US

V. Phone/Fax

Practice location:
  • Phone: 319-363-8303
  • Fax: 319-364-4659
Mailing address:
  • Phone: 319-363-8303
  • Fax: 319-364-4659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number20679
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number20679
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: