Healthcare Provider Details

I. General information

NPI: 1033170741
Provider Name (Legal Business Name): CHANDRA K WIEWEL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 11/24/2020
Certification Date: 11/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 HIGHWAY K
O FALLON MO
63366-8431
US

IV. Provider business mailing address

PO BOX 955534
SAINT LOUIS MO
63195-5534
US

V. Phone/Fax

Practice location:
  • Phone: 636-379-4590
  • Fax: 636-669-2401
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2005014704
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: