Provider Demographics
NPI:1528027794
Name:WIEDEMER, WILLIAM J (DPM)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:J
Last Name:WIEDEMER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 LOGAN BLVD
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16602-4165
Mailing Address - Country:US
Mailing Address - Phone:814-943-3668
Mailing Address - Fax:814-942-7635
Practice Address - Street 1:711 LOGAN BLVD
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602-4165
Practice Address - Country:US
Practice Address - Phone:814-943-3668
Practice Address - Fax:814-942-7635
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC004522L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000505853OtherHIGHMARK BLUE SHIELD INDV
PA000546370OtherHIGHMARK BLUE SHLD GRP
PA0018087500001Medicaid
PA599562Medicare PIN