Provider Demographics
NPI:1083341515
Name:WEIDERT, DUSTIN MICHAEL (OD)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:MICHAEL
Last Name:WEIDERT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 CONNELL PARK LN
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-6539
Mailing Address - Country:US
Mailing Address - Phone:225-924-2020
Mailing Address - Fax:225-924-2089
Practice Address - Street 1:2468 LOUISIANA AVE
Practice Address - Street 2:
Practice Address - City:LUTCHER
Practice Address - State:LA
Practice Address - Zip Code:70071-5411
Practice Address - Country:US
Practice Address - Phone:225-869-5043
Practice Address - Fax:225-869-8400
Is Sole Proprietor?:No
Enumeration Date:2022-08-04
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1974-920AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1974-920ATOtherLA OD LICENSE