Provider Demographics
NPI:1154633857
Name:WIEDOWER, ERIC R (DO)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:R
Last Name:WIEDOWER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7714 POPLAR AVE STE 200
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-3941
Mailing Address - Country:US
Mailing Address - Phone:901-683-0055
Mailing Address - Fax:901-922-6722
Practice Address - Street 1:7945 WOLF RIVER BLVD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1733
Practice Address - Country:US
Practice Address - Phone:901-683-0055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-10
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3015207RH0003X
MS24301207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08484348Medicaid
TNQ022586Medicaid
MS503107YJ6CMedicare PIN
MS02720541Medicaid