Provider Demographics
NPI:1194785303
Name:WIEMAR, KENNETH E (M D)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:E
Last Name:WIEMAR
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1919 S WHEELING AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5638
Mailing Address - Country:US
Mailing Address - Phone:918-748-7570
Mailing Address - Fax:918-748-7573
Practice Address - Street 1:1919 S WHEELING AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5638
Practice Address - Country:US
Practice Address - Phone:918-748-7570
Practice Address - Fax:918-748-7573
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12545174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK731346102OtherFEDERAL TAX ID
OK100162400AMedicaid
OKD35406Medicare UPIN
OKOK100283Medicare PIN