Healthcare Provider Details

I. General information

NPI: 1922091370
Provider Name (Legal Business Name): MICHAEL I WIENER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1124 E RIDGEWOOD AVE STE 201
RIDGEWOOD NJ
07450-3943
US

IV. Provider business mailing address

514 LYDIA LN
WYCKOFF NJ
07481-1711
US

V. Phone/Fax

Practice location:
  • Phone: 201-881-7282
  • Fax:
Mailing address:
  • Phone: 201-891-7793
  • Fax: 201-368-9618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberAW8163812
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MB03506400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: