Provider Demographics
NPI:1033114871
Name:WIEDEL, GREGORY L (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:L
Last Name:WIEDEL
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 1411
Mailing Address - Street 2:
Mailing Address - City:HURON
Mailing Address - State:SD
Mailing Address - Zip Code:57350-1411
Mailing Address - Country:US
Mailing Address - Phone:605-352-8767
Mailing Address - Fax:605-352-8784
Practice Address - Street 1:455 KANSAS AVE SE
Practice Address - Street 2:
Practice Address - City:HURON
Practice Address - State:SD
Practice Address - Zip Code:57350-2522
Practice Address - Country:US
Practice Address - Phone:605-352-8767
Practice Address - Fax:605-352-8784
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD3959207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0003961OtherWELLMARK
SD110105454OtherRAILROAD MEDICARE
SD3959OtherDAKOTACARE
SD6002990Medicaid
SD110105454OtherRAILROAD MEDICARE
SDG07543Medicare UPIN