Provider Demographics
NPI:1326137407
Name:MICHAEL, WEDAD S (MD)
Entity Type:Individual
Prefix:DR
First Name:WEDAD
Middle Name:S
Last Name:MICHAEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 E ROYAL AVE
Mailing Address - Street 2:
Mailing Address - City:LINWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08221-2157
Mailing Address - Country:US
Mailing Address - Phone:609-601-0779
Mailing Address - Fax:
Practice Address - Street 1:54 W JIMMIE LEEDS RD STE 14
Practice Address - Street 2:
Practice Address - City:GALLOWAY
Practice Address - State:NJ
Practice Address - Zip Code:08205-9438
Practice Address - Country:US
Practice Address - Phone:609-677-5777
Practice Address - Fax:609-677-1711
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2021-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05942900207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6425305Medicaid
NJ223635100OtherEIN, EMPLOYER ID NUMBER
NJ223635100OtherEIN, EMPLOYER ID NUMBER
NJ612497Medicare PIN