Provider Demographics
NPI:1205072931
Name:WIESNER, MARK G (PHD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:G
Last Name:WIESNER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:5677 OBERLIN DR STE 106
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-1741
Mailing Address - Country:US
Mailing Address - Phone:858-457-8419
Mailing Address - Fax:858-457-0670
Practice Address - Street 1:5677 OBERLIN DR STE 106
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-1741
Practice Address - Country:US
Practice Address - Phone:858-457-8419
Practice Address - Fax:858-457-0670
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-30
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA5996103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical