Basic Information
| Provider Information | |||||||||
| NPI: | 1154304939 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIESNER | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 555 PROSPECT AVE | ||||||||
| Address2: | |||||||||
| City: | ESTES PARK | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805176312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9705862200 | ||||||||
| FaxNumber: | 9705774536 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 PROSPECT AVE | ||||||||
| Address2: | |||||||||
| City: | ESTES PARK | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805176312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9705862200 | ||||||||
| FaxNumber: | 9705774536 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/25/2005 | ||||||||
| LastUpdateDate: | 08/28/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 31069 | CO | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0725614 | 05 | IA | MEDICAID | WIA4011 | 01 | CO | ANTHEM BCBS | OTHER | 01310697 | 05 | CO | MEDICAID | 107825900 | 05 | WY | MEDICAID | 841287602 | 01 | CO | CHAMPUS | OTHER |