MEDICARE: DR. RICHARD JOHN WIETING M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	225618	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639158678
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD JOHN WIETING M.D.

Provider Business Mailing Address
First Line	:	38 ROLLING RD
Second Line	:
City	:	MILLER PLACE
State	:	NY
Zip	:	11764-2217
Country	:	US
Telephone Number	:	631-331-0633
Fax Number	:

Provider Business Practice Location Address
First Line	:	116 TERRYVILLE RD
Second Line	:
City	:	PORT JEFFERSON STATION
State	:	NY
Zip	:	11776-1329
Country	:	US
Telephone Number	:	631-928-2002
Fax Number	:	631-928-4934

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/10/2006
Last Update Date	:	07/08/2007

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