Provider Demographics
NPI:1184692667
Name:WIENER, EDWARD L (DO)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:L
Last Name:WIENER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21110 BISCAYNE BLVD SUITE 400
Mailing Address - Street 2:
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33180
Mailing Address - Country:US
Mailing Address - Phone:305-933-8622
Mailing Address - Fax:305-682-8430
Practice Address - Street 1:21110 BISCAYNE BLVD SUITE 400
Practice Address - Street 2:
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180
Practice Address - Country:US
Practice Address - Phone:305-933-8622
Practice Address - Fax:305-682-8430
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS3845208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL82412OtherBLUECROSS BLUESHIELD
FL064580000Medicaid
FL82412WMedicare PIN
FLE34842Medicare UPIN
FL82412OtherBLUECROSS BLUESHIELD