Provider Demographics
NPI:1194739672
Name:WIESE, FREDERICK KEYSER (MD)
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:KEYSER
Last Name:WIESE
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 1:18 ROBERTS ROAD
Mailing Address - Street 2:
Mailing Address - City:CANAAN
Mailing Address - State:NH
Mailing Address - Zip Code:03741-1079
Mailing Address - Country:US
Mailing Address - Phone:603-523-4343
Mailing Address - Fax:603-523-4502
Practice Address - Street 1:18 ROBERTS ROAD
Practice Address - Street 2:
Practice Address - City:CANAAN
Practice Address - State:NH
Practice Address - Zip Code:03741
Practice Address - Country:US
Practice Address - Phone:603-523-4343
Practice Address - Fax:603-523-4502
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2019-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH6868207RC0000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY52023AMedicare PIN
NYRB6282Medicare PIN