Healthcare Provider Details

I. General information

NPI: 1346315017
Provider Name (Legal Business Name): RICHARD M WIET M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 11/22/2023
Certification Date: 11/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 N WINFIELD RD STE 424
WINFIELD IL
60190-1379
US

IV. Provider business mailing address

25 N WINFIELD RD STE 424
WINFIELD IL
60190-1379
US

V. Phone/Fax

Practice location:
  • Phone: 630-933-4056
  • Fax: 630-933-4057
Mailing address:
  • Phone: 630-933-4056
  • Fax: 630-933-4057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License Number036119686
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License Number4301087453
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: