Provider Demographics
NPI:1497867840
Name:WEDDELL, BRETT FREDERICK (OD)
Entity Type:Individual
Prefix:DR
First Name:BRETT
Middle Name:FREDERICK
Last Name:WEDDELL
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 1:116 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-3729
Mailing Address - Country:US
Mailing Address - Phone:574-533-7345
Mailing Address - Fax:574-533-5683
Practice Address - Street 1:116 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-3729
Practice Address - Country:US
Practice Address - Phone:574-533-7345
Practice Address - Fax:574-533-5683
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003139152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200378560AMedicaid
IN229260FMedicare ID - Type Unspecified
INU88057Medicare UPIN