Provider Demographics
NPI:1316989692
Name:WIERSEMA, MAURITS J (MD)
Entity type:Individual
Prefix:
First Name:MAURITS
Middle Name:J
Last Name:WIERSEMA
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 68
Mailing Address - Street 2:
Mailing Address - City:POLLOCKSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28573-0068
Mailing Address - Country:US
Mailing Address - Phone:252-635-3906
Mailing Address - Fax:252-224-0378
Practice Address - Street 1:2604 DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-4238
Practice Address - Country:US
Practice Address - Phone:252-636-4502
Practice Address - Fax:252-633-2785
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01039203A207RG0100X
NC2018-01881207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100176630Medicaid
IN100176630Medicaid
INM400029366Medicare PIN
IN925060LLLLMedicare PIN
INM400029366Medicare PIN