Provider Demographics
NPI:1316932148
Name:WETZNER, STEVEN (MD)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:
Last Name:WETZNER
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:PO BOX 9135
Mailing Address - Street 2:ATT SHARON SILVA
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-9135
Mailing Address - Country:US
Mailing Address - Phone:800-927-0002
Mailing Address - Fax:
Practice Address - Street 1:125 PARKER HILL AVE
Practice Address - Street 2:
Practice Address - City:ROXBURY CROSSING
Practice Address - State:MA
Practice Address - Zip Code:02120-2847
Practice Address - Country:US
Practice Address - Phone:617-754-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA367312085R0202X, 2085N0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2034255Medicaid
A59640Medicare UPIN
MAK08306Medicare ID - Type Unspecified