Provider Demographics
NPI:1992924559
Name:WIESE, WALTER SCOTT (DC)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:SCOTT
Last Name:WIESE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 S ROYAL AVE
Mailing Address - Street 2:
Mailing Address - City:EAGLE POINT
Mailing Address - State:OR
Mailing Address - Zip Code:97524-8620
Mailing Address - Country:US
Mailing Address - Phone:541-234-6440
Mailing Address - Fax:
Practice Address - Street 1:140 S ROYAL AVE
Practice Address - Street 2:
Practice Address - City:EAGLE POINT
Practice Address - State:OR
Practice Address - Zip Code:97524-8620
Practice Address - Country:US
Practice Address - Phone:541-234-6440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3778111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR164272Medicare PIN
ORR144456Medicare PIN