Provider Demographics
NPI:1134323736
Name:WIEDERHOLD, LEE ROY III (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:ROY
Last Name:WIEDERHOLD
Suffix:III
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77555-5302
Mailing Address - Country:US
Mailing Address - Phone:409-772-2222
Mailing Address - Fax:
Practice Address - Street 1:301 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77555-0462
Practice Address - Country:US
Practice Address - Phone:409-772-2531
Practice Address - Fax:409-772-1814
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM59762085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX213444702Medicaid
3847415682OtherMYUTMB 3847415682-COMMERCIAL NUMBER
TX213444703OtherMEDICAID CSHCN