=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922091370
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL I WIENER D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2005
-----------------------------------------------------
Last Update Date | 12/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1124 E RIDGEWOOD AVE STE 201
-----------------------------------------------------
City | RIDGEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07450-3943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-881-7282
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 514 LYDIA LN
-----------------------------------------------------
City | WYCKOFF
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07481-1711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-891-7793
-----------------------------------------------------
Fax | 201-368-9618
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | AW8163812
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 25MB03506400
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------