Basic Information
| Provider Information | |||||||||
| NPI: | 1316989692 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIERSEMA | ||||||||
| FirstName: | MAURITS | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 68 | ||||||||
| Address2: | |||||||||
| City: | POLLOCKSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285730068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2526353906 | ||||||||
| FaxNumber: | 2522240378 | ||||||||
| Practice Location | |||||||||
| Address1: | 2604 DR MARTIN LUTHER KING JR BLVD | ||||||||
| Address2: | |||||||||
| City: | NEW BERN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285624238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2526364502 | ||||||||
| FaxNumber: | 2526332785 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 02/15/2019 | ||||||||
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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 | 207RG0100X | 01039203A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | 2018-01881 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 100176630 | 05 | IN | MEDICAID |