Provider Demographics
NPI:1144203423
Name:WIEDEMAN, JEAN A (MD)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:A
Last Name:WIEDEMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 HERON PL
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-7512
Mailing Address - Country:US
Mailing Address - Phone:530-759-0726
Mailing Address - Fax:
Practice Address - Street 1:2516 STOCKTON BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2208
Practice Address - Country:US
Practice Address - Phone:916-734-3557
Practice Address - Fax:916-734-7890
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC0431372080P0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C0431370OtherMEDICAL#
CAF74255Medicare UPIN