Basic Information
| Provider Information | |||||||||
| NPI: | 1396790754 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ELISE R WIESNER MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 N PORTER AVE | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730716424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053297066 | ||||||||
| FaxNumber: | 4053606315 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 N PORTER AVE | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730716424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053297066 | ||||||||
| FaxNumber: | 4053606315 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 01/22/2008 | ||||||||
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| AuthorizedOfficialLastName: | WIESNER | ||||||||
| AuthorizedOfficialFirstName: | ELISE | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4053297066 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 18219 | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100826940A | 05 | OK | MEDICAID |