Individual
JON D WIESE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
521 W STATE ROAD 434, SUITE 301, LONGWOOD, FL 32750-5166
(407) 767-5808
(407) 767-5892
Mailing address
521 W STATE ROAD 434, SUITE 301, LONGWOOD, FL 32750-5166
(407) 767-5808
(407) 767-5892
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
ME54060
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
049597200
—
FL
01
—
ME54060
MEDICAL LICENSE
FL
Enumeration date
11/15/2006
Last updated
11/14/2016
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