Provider Demographics
NPI:1902078512
Name:JON D WIESE MD FACS PA
Entity Type:Organization
Organization Name:JON D WIESE MD FACS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:D
Authorized Official - Last Name:WIESE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-332-1995
Mailing Address - Street 1:521 W STATE ROAD 434
Mailing Address - Street 2:SUITE 305
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-4984
Mailing Address - Country:US
Mailing Address - Phone:407-332-1995
Mailing Address - Fax:407-332-1404
Practice Address - Street 1:521 W STATE ROAD 434
Practice Address - Street 2:SUITE 305
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-4984
Practice Address - Country:US
Practice Address - Phone:407-332-1995
Practice Address - Fax:407-332-1404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-24
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME54060208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK1083Medicare UPIN