Basic Information
| Provider Information | |||||||||
| NPI: | 1104815380 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIELAND | ||||||||
| FirstName: | LAWRENCE | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2350 BUHNE ST | ||||||||
| Address2: | A | ||||||||
| City: | EUREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955013238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074434593 | ||||||||
| FaxNumber: | 7074436447 | ||||||||
| Practice Location | |||||||||
| Address1: | 2350 BUHNE ST | ||||||||
| Address2: | A | ||||||||
| City: | EUREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955013238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074434593 | ||||||||
| FaxNumber: | 7074436447 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2005 | ||||||||
| LastUpdateDate: | 01/12/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 173000000X | C36056 | CA | N | Other Service Providers | Legal Medicine | 208D00000X | C36056 | CA | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | C36056 | 01 | CA | MEDICAL LICENSE | OTHER | 00C360560 | 05 | CA | MEDICAID |