Provider Demographics
NPI:1538468947
Name:WEEDEN, WILLIS FRED JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIS
Middle Name:FRED
Last Name:WEEDEN
Suffix:JR
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 1:5005 STATE ROUTE 64
Mailing Address - Street 2:
Mailing Address - City:CANANDAIGUA
Mailing Address - State:NY
Mailing Address - Zip Code:14424-9358
Mailing Address - Country:US
Mailing Address - Phone:585-229-2595
Mailing Address - Fax:
Practice Address - Street 1:5005 STATE ROUTE 64
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-9358
Practice Address - Country:US
Practice Address - Phone:585-229-2595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-24
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY131238207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine