Provider Demographics
NPI:1972591980
Name:WIECK, ROBERT A (DO)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:A
Last Name:WIECK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 248865
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73124-8865
Mailing Address - Country:US
Mailing Address - Phone:405-257-6272
Mailing Address - Fax:405-257-6273
Practice Address - Street 1:1509 S INDIAN RD
Practice Address - Street 2:
Practice Address - City:WEWOKA
Practice Address - State:OK
Practice Address - Zip Code:74884-9781
Practice Address - Country:US
Practice Address - Phone:405-257-6272
Practice Address - Fax:405-257-6273
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2762207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKD27296Medicare UPIN