Provider Demographics
NPI:1225287444
Name:WIEDRICH, JEFFREY RYAN (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:RYAN
Last Name:WIEDRICH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FORT MORGAN
Mailing Address - State:CO
Mailing Address - Zip Code:80701-2036
Mailing Address - Country:US
Mailing Address - Phone:806-336-7105
Mailing Address - Fax:
Practice Address - Street 1:1100 MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT MORGAN
Practice Address - State:CO
Practice Address - Zip Code:80701-2036
Practice Address - Country:US
Practice Address - Phone:806-336-7105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-11
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2664152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist