Provider Demographics
NPI:1447414461
Name:WIEDERHOLT, NATHAN HENRY (OD)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:HENRY
Last Name:WIEDERHOLT
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 1:322 MOUNT RUSHMORE RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:CUSTER
Mailing Address - State:SD
Mailing Address - Zip Code:57730-1936
Mailing Address - Country:US
Mailing Address - Phone:605-673-2716
Mailing Address - Fax:605-673-2017
Practice Address - Street 1:322 MOUNT RUSHMORE RD
Practice Address - Street 2:SUITE 120
Practice Address - City:CUSTER
Practice Address - State:SD
Practice Address - Zip Code:57730-1936
Practice Address - Country:US
Practice Address - Phone:605-673-2716
Practice Address - Fax:605-673-2017
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-18
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD656152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9203883Medicaid
S103300Medicare PIN
6339560001Medicare NSC