Basic Information
| Provider Information | |||||||||
| NPI: | 1073593927 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIEST | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RPAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11835 RT 9W | ||||||||
| Address2: | |||||||||
| City: | WEST COXSACKIE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121923605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187319000 | ||||||||
| FaxNumber: | 5187319119 | ||||||||
| Practice Location | |||||||||
| Address1: | 11835 RT 9W | ||||||||
| Address2: | |||||||||
| City: | WEST COXSACKIE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121923605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187319000 | ||||||||
| FaxNumber: | 5187319119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2006 | ||||||||
| LastUpdateDate: | 01/22/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 0039611 | NY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 275191 | 01 | WELLCARE NY | OTHER | 4937930001 | 01 | NY | MEDICARE DME | OTHER | DW05762L10 | 01 | BLUE CROSS | OTHER | 10050348 | 01 | CDPHP | OTHER | 000406870004 | 01 | BLUE SHIELD NENY | OTHER |