Provider Demographics
NPI:1922091370
Name:WIENER, MICHAEL I (DO)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:I
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 1:514 LYDIA LN
Mailing Address - Street 2:
Mailing Address - City:WYCKOFF
Mailing Address - State:NJ
Mailing Address - Zip Code:07481-1711
Mailing Address - Country:US
Mailing Address - Phone:201-891-7793
Mailing Address - Fax:201-368-9618
Practice Address - Street 1:1124 E RIDGEWOOD AVE STE 201
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-3943
Practice Address - Country:US
Practice Address - Phone:201-881-7282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJAW8163812207Q00000X
NJ25MB03506400207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1569309Medicaid
NJC56557Medicare UPIN
NJ1569309Medicaid