MEDICARE: DR. DEVIN RICHARD WIESECKEL OD

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	152W00000X	Optometrist	OPT003013	GA

General Provider Information

NPI Number	:	1649790262
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DEVIN RICHARD WIESECKEL OD

Provider Business Mailing Address
First Line	:	4280 E WEST CONNECTOR SE
Second Line	:
City	:	SMYRNA
State	:	GA
Zip	:	30082-4804
Country	:	US
Telephone Number	:	770-435-4457
Fax Number	:

Provider Business Practice Location Address
First Line	:	4280 E WEST CONNECTOR SE
Second Line	:
City	:	SMYRNA
State	:	GA
Zip	:	30082-4804
Country	:	US
Telephone Number	:	770-435-4457
Fax Number	:	770-435-4555

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

Provider Enumeration Date	:	06/24/2017
Last Update Date	:	07/21/2022

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