Provider Demographics
NPI:1194245043
Name:WIESSNER, ERIC JOHN (OD)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:JOHN
Last Name:WIESSNER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 E ALDER ST STE 1
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-2073
Mailing Address - Country:US
Mailing Address - Phone:509-527-3937
Mailing Address - Fax:509-529-4750
Practice Address - Street 1:5075 LEETSDALE DR
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80246-8176
Practice Address - Country:US
Practice Address - Phone:303-333-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-21
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60767319152W00000X
COOPT.0003608152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty