Provider Demographics
NPI:1366738155
Name:WIESE, COURTNEY GRAY (MD)
Entity type:Individual
Prefix:DR
First Name:COURTNEY
Middle Name:GRAY
Last Name:WIESE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:COURTNEY
Other - Middle Name:GRAY
Other - Last Name:FOOTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 4046
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-4046
Mailing Address - Country:US
Mailing Address - Phone:417-269-5712
Mailing Address - Fax:417-269-7567
Practice Address - Street 1:3850 S NATIONAL AVE STE 400
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5287
Practice Address - Country:US
Practice Address - Phone:417-269-6850
Practice Address - Fax:417-269-5830
Is Sole Proprietor?:No
Enumeration Date:2011-06-21
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10040931207V00000X
MO2019004912207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology