Provider Demographics
NPI:1487866059
Name:WIEDENBECK, TROY L (MD)
Entity Type:Individual
Prefix:
First Name:TROY
Middle Name:L
Last Name:WIEDENBECK
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 1:1155 MILL ST # MCM14
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-1576
Mailing Address - Country:US
Mailing Address - Phone:775-982-5262
Mailing Address - Fax:775-982-5496
Practice Address - Street 1:1500 E 2ND ST
Practice Address - Street 2:SUITE 400
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-1262
Practice Address - Country:US
Practice Address - Phone:775-982-5000
Practice Address - Fax:775-982-2410
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV15302207RI0011X, 207RC0000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV108190Medicare PIN
NVV108192Medicare PIN
NVV109492Medicare PIN