Provider Demographics
NPI:1538383070
Name:WIETHOP, JUSTIN (DC)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:WIETHOP
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 PINE TRL
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-4216
Mailing Address - Country:US
Mailing Address - Phone:314-471-8303
Mailing Address - Fax:314-842-9899
Practice Address - Street 1:12032 TESSON FERRY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-1727
Practice Address - Country:US
Practice Address - Phone:314-849-1331
Practice Address - Fax:314-842-9899
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007001660111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor