Provider Demographics
NPI:1164708905
Name:WIEDMAR, JOAN C (PT)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:C
Last Name:WIEDMAR
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9513 DABNEY CARR DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-6228
Mailing Address - Country:US
Mailing Address - Phone:502-267-7397
Mailing Address - Fax:
Practice Address - Street 1:6008 BROWNSBORO PARK BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-1295
Practice Address - Country:US
Practice Address - Phone:502-899-4760
Practice Address - Fax:502-899-4719
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-25
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY001085208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation