Healthcare Provider Details

I. General information

NPI: 1952475444
Provider Name (Legal Business Name): RICHARD WIENER O,D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 06/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 E 6TH ST
CONNERSVILLE IN
47331-2025
US

IV. Provider business mailing address

PO BOX 427
CONNERSVILLE IN
47331-0427
US

V. Phone/Fax

Practice location:
  • Phone: 765-825-4127
  • Fax: 765-827-6577
Mailing address:
  • Phone: 765-825-4127
  • Fax: 765-827-6577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberIN1652
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: