Healthcare Provider Details

I. General information

NPI: 1316333446
Provider Name (Legal Business Name): MATTHEW L. WIESE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2015
Last Update Date: 06/06/2023
Certification Date: 06/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

818 ELLICOTT ST
BUFFALO NY
14203-1021
US

IV. Provider business mailing address

1001 MAIN ST FL 5
BUFFALO NY
14203-1009
US

V. Phone/Fax

Practice location:
  • Phone: 716-323-2000
  • Fax: 716-323-0293
Mailing address:
  • Phone: 716-323-0220
  • Fax: 716-323-0293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number274395
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number298763
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number274395
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number298763
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: