Provider Demographics
NPI:1205855509
Name:WIEDEMAN, GARY MARK (DC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:MARK
Last Name:WIEDEMAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2716 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-6920
Mailing Address - Country:US
Mailing Address - Phone:970-353-5300
Mailing Address - Fax:970-353-5332
Practice Address - Street 1:2716 23RD AVE
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-6920
Practice Address - Country:US
Practice Address - Phone:970-353-5300
Practice Address - Fax:970-353-5332
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1689111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC542838Medicare PIN
COU05797Medicare UPIN