Provider Demographics
NPI:1992774772
Name:WIEFERICH, JAMES ROGER (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:ROGER
Last Name:WIEFERICH
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 449
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-0449
Mailing Address - Country:US
Mailing Address - Phone:740-374-4500
Mailing Address - Fax:740-374-5887
Practice Address - Street 1:40 WHITE OAK PROFESSIONAL CTR
Practice Address - Street 2:
Practice Address - City:VINCENT
Practice Address - State:OH
Practice Address - Zip Code:45784-9117
Practice Address - Country:US
Practice Address - Phone:740-678-2374
Practice Address - Fax:740-678-8139
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-15
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3506005207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0052785000Medicaid
OHP01019339OtherMCR RAILROAD
OH0790916Medicaid
OH000000678794OtherANTHEM
OH000000699796OtherANTHEM
WV0052785000Medicaid
B67574Medicare UPIN
OH0672449Medicare PIN
OH000000699796OtherANTHEM
OHP01019339OtherMCR RAILROAD