Provider Demographics
NPI:1437577129
Name:WIEDEMANN, MICHELLE LOPEZ (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LOPEZ
Last Name:WIEDEMANN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:LINDSAY
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6949 GOOD SAMARITAN DR STE 210
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45247-5205
Mailing Address - Country:US
Mailing Address - Phone:513-931-2400
Mailing Address - Fax:513-931-0132
Practice Address - Street 1:6949 GOOD SAMARITAN DR STE 210
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45247-5205
Practice Address - Country:US
Practice Address - Phone:513-931-2400
Practice Address - Fax:513-931-0132
Is Sole Proprietor?:No
Enumeration Date:2014-03-31
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.135693207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine