Provider Demographics
NPI:1053367912
Name:WIESEN, MARK (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:WIESEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:870 PALISADE AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-3419
Mailing Address - Country:US
Mailing Address - Phone:201-836-5655
Mailing Address - Fax:
Practice Address - Street 1:870 PALISADE AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-3419
Practice Address - Country:US
Practice Address - Phone:201-836-5655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA39387207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0712507Medicaid
NJC52950Medicare UPIN
NJ086123Medicare ID - Type Unspecified