Basic Information
| Provider Information | |||||||||
| NPI: | 1144230517 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEISE | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NIEMANN | ||||||||
| OtherFirstName: | KATHERINE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | OD. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1716 UNIVERSITY BLVD | ||||||||
| Address2: | HPB G080A | ||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352940010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059752020 | ||||||||
| FaxNumber: | 2059346755 | ||||||||
| Practice Location | |||||||||
| Address1: | 1716 UNIVERSITY BLVD | ||||||||
| Address2: | HPB G080A | ||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352940010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059752020 | ||||||||
| FaxNumber: | 2059346755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 11/30/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | SA33TA287 | AL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 51035147 | 01 | AL | BCBS OF ALABAMA | OTHER | U57411 | 01 | AL | VIVA | OTHER | 41002840 | 01 | MEDICARE RAILROAD | OTHER | 51035887 | 01 | AL | BCBS | OTHER | 000035887 | 05 | AL | MEDICAID | 04500362 | 05 | MS | MEDICAID |