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General NPI Number Information
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NPI Number | 1902078512
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Entity Type | Organization
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Legal Business Name | JON D WIESE MD FACS PA
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Dates
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Enumeration Date | 03/24/2008
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Last Update Date | 04/03/2008
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Provider Practice Location Address
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Address Line | 521 W STATE ROAD 434 SUITE 305
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City | LONGWOOD
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State | FL
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Zip | 32750-4984
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Country | US
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Telephone | 407-332-1995
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Fax | 407-332-1404
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Provider Business Mailing Address
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Address Line | 521 W STATE ROAD 434 SUITE 305
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City | LONGWOOD
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State | FL
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Zip | 32750-4984
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Country | US
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Telephone | 407-332-1995
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Fax | 407-332-1404
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JON D. WIESE
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Credential | M.D.
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Telephone | 407-332-1995
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | ME54060
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License Number State | FL
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