Healthcare Provider Details

I. General information

NPI: 1770574014
Provider Name (Legal Business Name): RICHARD JOEL WEIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2005
Last Update Date: 12/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3625 PARK PL W STE 100
MISHAWAKA IN
46545-3561
US

IV. Provider business mailing address

3625 PARK PL W STE 100
MISHAWAKA IN
46545-3561
US

V. Phone/Fax

Practice location:
  • Phone: 574-232-5963
  • Fax: 574-287-7988
Mailing address:
  • Phone: 574-232-5963
  • Fax: 574-287-7988

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01034947
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: