MEDICARE: JON D WIESE MD

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	208600000X	Surgery Physician	ME54060	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ME54060	OTHER	FL	MEDICAL LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1952474561
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JON D WIESE MD

Provider Business Mailing Address
First Line	:	521 W STATE ROAD 434
Second Line	:	SUITE 301
City	:	LONGWOOD
State	:	FL
Zip	:	32750-5166
Country	:	US
Telephone Number	:	407-767-5808
Fax Number	:	407-767-5892

Provider Business Practice Location Address
First Line	:	521 W STATE ROAD 434
Second Line	:	SUITE 301
City	:	LONGWOOD
State	:	FL
Zip	:	32750-5166
Country	:	US
Telephone Number	:	407-767-5808
Fax Number	:	407-767-5892

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

Provider Enumeration Date	:	11/15/2006
Last Update Date	:	11/14/2016

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Directions to “ JON D WIESE MD” Practice Location

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