Provider Demographics
NPI:1679148480
Name:WIEMKEN, BRADLEY
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:WIEMKEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:558 HUNTMERE DR
Mailing Address - Street 2:
Mailing Address - City:BAY VILLAGE
Mailing Address - State:OH
Mailing Address - Zip Code:44140-2540
Mailing Address - Country:US
Mailing Address - Phone:440-829-5171
Mailing Address - Fax:
Practice Address - Street 1:3700 KOLBE RD
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-1611
Practice Address - Country:US
Practice Address - Phone:440-960-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-24
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPP-000470719213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery