Provider Demographics
NPI:1861616732
Name:WIESENAUER, CHAD A (MD)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:A
Last Name:WIESENAUER
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 1:234 E GRAY ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1900
Mailing Address - Country:US
Mailing Address - Phone:502-588-0390
Mailing Address - Fax:502-584-5437
Practice Address - Street 1:234 E GRAY ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1900
Practice Address - Country:US
Practice Address - Phone:502-588-0390
Practice Address - Fax:502-584-5437
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2017-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01053500A2086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01053500AOtherSTATE LICENSE NUMBER
KY7100008600Medicaid