Provider Demographics
NPI:1992733372
Name:WIETING, JERRY MICHAEL (DO)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:MICHAEL
Last Name:WIETING
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 367
Mailing Address - Street 2:
Mailing Address - City:HARROGATE
Mailing Address - State:TN
Mailing Address - Zip Code:37752-0367
Mailing Address - Country:US
Mailing Address - Phone:423-869-7193
Mailing Address - Fax:423-869-7195
Practice Address - Street 1:424 N BROAD ST
Practice Address - Street 2:
Practice Address - City:NEW TAZEWELL
Practice Address - State:TN
Practice Address - Zip Code:37825-6606
Practice Address - Country:US
Practice Address - Phone:423-869-7193
Practice Address - Fax:423-869-7195
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101012414208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIF45913Medicare UPIN