Individual
KEVIN M WIESMANN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
9205 SW BARNES RD, PORTLAND, OR 97225-6603
(503) 216-4830
Mailing address
PO BOX 25180, PORTLAND, OR 97298-0180
(503) 797-6356
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
170867
OR
2085R0202X
Diagnostic Radiology Physician
25.000136
OH
2085R0202X
Diagnostic Radiology Physician
47145
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
679483100
—
MN
Enumeration date
01/12/2006
Last updated
02/08/2017
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