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General NPI Number Information
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NPI Number | 1063040475
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Entity Type | Individual
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Provider Name | ERWIN WIETRICK
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Gender | Male
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Dates
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Enumeration Date | 03/31/2020
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Last Update Date | 01/30/2026
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Provider Practice Location Address
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Address Line | 6147 STATE ROUTE 122 STE 200
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City | MIDDLETOWN
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State | OH
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Zip | 45005-5201
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Country | US
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Telephone | 513-261-3500
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Fax | 513-261-3509
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Provider Business Mailing Address
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Address Line | 1 PRESTIGE PL STE 550
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City | MIAMISBURG
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State | OH
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Zip | 45342-6115
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Country | US
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Telephone | 937-762-1310
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Fax | 937-522-8068
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 34.017377
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License Number State | OH
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 06262
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License Number State | KY
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