Basic Information
| Provider Information | |||||||||
| NPI: | 1144743626 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIESER | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2023 PULASKI HWY | ||||||||
| Address2: | |||||||||
| City: | HAVRE DE GRACE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210782137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109396477 | ||||||||
| FaxNumber: | 4109396555 | ||||||||
| Practice Location | |||||||||
| Address1: | 2023 PULASKI HWY | ||||||||
| Address2: | |||||||||
| City: | HAVRE DE GRACE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109396477 | ||||||||
| FaxNumber: | 4109396555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2017 | ||||||||
| LastUpdateDate: | 11/13/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | I3-0001402 | DE | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.