Individual
MR. MARK L WIESNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.O.
Contact information
Practice address
555 PROSPECT AVE, ESTES PARK, CO 80517-6312
(970) 586-2200
(970) 577-4536
Mailing address
555 PROSPECT AVE, ESTES PARK, CO 80517-6312
(970) 586-2200
(970) 577-4536
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
31069
CO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
01310697
—
CO
05
—
0725614
—
IA
05
—
107825900
—
WY
01
—
841287602
CHAMPUS
CO
01
—
WIA4011
ANTHEM BCBS
CO
Enumeration date
11/25/2005
Last updated
08/28/2013
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