Provider Demographics
NPI:1023000304
Name:WEDEMEYER, ELISSA R (OD)
Entity Type:Individual
Prefix:DR
First Name:ELISSA
Middle Name:R
Last Name:WEDEMEYER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6026 HIGHWAY 6
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-4163
Mailing Address - Country:US
Mailing Address - Phone:281-499-2600
Mailing Address - Fax:281-499-6556
Practice Address - Street 1:6026 HIGHWAY 6
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77459-4163
Practice Address - Country:US
Practice Address - Phone:281-499-2600
Practice Address - Fax:281-499-6556
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTX4167TG152W00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU05302Medicare UPIN
TX00E44NMedicare ID - Type Unspecified