Provider Demographics
NPI:1467582536
Name:WIEDER, ALAN JONAH (MD)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:JONAH
Last Name:WIEDER
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 1:215 ROCKAWAY TPKE
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:NY
Mailing Address - Zip Code:11559-1216
Mailing Address - Country:US
Mailing Address - Phone:516-374-5024
Mailing Address - Fax:
Practice Address - Street 1:215 ROCKAWAY TPKE
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:NY
Practice Address - Zip Code:11559-1216
Practice Address - Country:US
Practice Address - Phone:516-374-5024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY202090207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01715351Medicaid
NY770971Medicare ID - Type Unspecified
NY01715351Medicaid