Provider Demographics
NPI:1215190558
Name:WIEDERHOLT, CYNTHIA XAKELLIS (MD)
Entity Type:Individual
Prefix:DR
First Name:CYNTHIA
Middle Name:XAKELLIS
Last Name:WIEDERHOLT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CYNTHIA
Other - Middle Name:XAKELLIS
Other - Last Name:PLACKIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:FAST TRACK URGENT CARE
Mailing Address - Street 2:2686 N. HIGHWAY 67
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63023-1438
Mailing Address - Country:US
Mailing Address - Phone:314-921-7300
Mailing Address - Fax:
Practice Address - Street 1:FAST TRACK URGENT CARE
Practice Address - Street 2:2686 N HIGHWAY 67
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63023-1438
Practice Address - Country:US
Practice Address - Phone:314-921-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-07
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009001470207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine