MEDICARE: KEVIN GERARD WIETECHA DO

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	207RE0101X	Endocrinology, Diabetes & Metabolism Physician	34-00-6364W	OH

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	:	1669450557
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN GERARD WIETECHA DO

Provider Business Mailing Address
First Line	:	4634 HILLS AND DALES RD NW
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44708-1510
Country	:	US
Telephone Number	:	330-477-0255
Fax Number	:	330-477-7266

Provider Business Practice Location Address
First Line	:	4634 HILLS AND DALES RD NW
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44708-1510
Country	:	US
Telephone Number	:	330-477-0255
Fax Number	:	330-477-7266

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

Provider Enumeration Date	:	01/03/2006
Last Update Date	:	07/09/2007

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