Provider Demographics
NPI:1538118328
Name:WIEDEMER, DAVID (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:WIEDEMER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1650 RAMBLEWOOD DR
Mailing Address - Street 2:STE 100
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-7396
Mailing Address - Country:US
Mailing Address - Phone:517-332-1200
Mailing Address - Fax:517-351-7122
Practice Address - Street 1:1650 RAMBLEWOOD DR
Practice Address - Street 2:STE 100
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-7396
Practice Address - Country:US
Practice Address - Phone:517-332-1200
Practice Address - Fax:517-351-7122
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
MIDW039509207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIB45365Medicare UPIN