Provider Demographics
NPI:1376736140
Name:WIEDMEYER, JERILOU A (MD)
Entity Type:Individual
Prefix:
First Name:JERILOU
Middle Name:A
Last Name:WIEDMEYER
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 1:1650 S 41ST ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-7316
Mailing Address - Country:US
Mailing Address - Phone:920-320-4500
Mailing Address - Fax:920-320-4584
Practice Address - Street 1:1650 S 41ST ST
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-7316
Practice Address - Country:US
Practice Address - Phone:920-320-4500
Practice Address - Fax:920-320-4584
Is Sole Proprietor?:No
Enumeration Date:2007-08-24
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44729207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine