Provider Demographics
NPI:1356327829
Name:WEDDLE, RICHARD A (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:A
Last Name:WEDDLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2920 MCINTIRE DR
Mailing Address - Street 2:SUITE 310
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-4221
Mailing Address - Country:US
Mailing Address - Phone:812-331-0233
Mailing Address - Fax:812-331-0287
Practice Address - Street 1:2920 MCINTIRE DR
Practice Address - Street 2:SUITE 310
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-4221
Practice Address - Country:US
Practice Address - Phone:812-331-0233
Practice Address - Fax:812-331-0287
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-16
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01031299207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100184520Medicaid
INC87056Medicare UPIN
IN545460Medicare ID - Type Unspecified