Provider Demographics
NPI:1093869869
Name:WEDEKIND, MARK (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:WEDEKIND
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 1:2040 148TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-5527
Mailing Address - Country:US
Mailing Address - Phone:425-641-9202
Mailing Address - Fax:
Practice Address - Street 1:2040 148TH AVE NE
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-5527
Practice Address - Country:US
Practice Address - Phone:425-641-9202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00001576152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB20751Medicare ID - Type Unspecified
WAU03029Medicare UPIN