Provider Demographics
NPI:1548226970
Name:WIEDOWER, RONALD C (MD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:C
Last Name:WIEDOWER
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 1:12221 N MO PAC EXPY
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-2415
Mailing Address - Country:US
Mailing Address - Phone:512-907-8748
Mailing Address - Fax:512-901-8755
Practice Address - Street 1:1717 ROTARY DR
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77338-5235
Practice Address - Country:US
Practice Address - Phone:281-272-6277
Practice Address - Fax:281-272-6281
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG47462085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX135895403Medicaid
TX82R050Medicare PIN
TX135895403Medicaid
TX300106165Medicare PIN