Provider Demographics
NPI:1104815380
Name:WIELAND, LAWRENCE JOSEPH (MD)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:JOSEPH
Last Name:WIELAND
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 1:2350 BUHNE ST
Mailing Address - Street 2:A
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-3238
Mailing Address - Country:US
Mailing Address - Phone:707-443-4593
Mailing Address - Fax:707-443-6447
Practice Address - Street 1:2350 BUHNE ST
Practice Address - Street 2:A
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-3238
Practice Address - Country:US
Practice Address - Phone:707-443-4593
Practice Address - Fax:707-443-6447
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC36056173000000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC36056OtherMEDICAL LICENSE
CA00C360560Medicaid
CAA36155Medicare UPIN