Provider Demographics
NPI:1578768081
Name:WEDELL, JAMES ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:ROBERT
Last Name:WEDELL
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 1:8637 WINDING WAY
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-6406
Mailing Address - Country:US
Mailing Address - Phone:916-220-7363
Mailing Address - Fax:
Practice Address - Street 1:2433 MARCONI AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95821-4807
Practice Address - Country:US
Practice Address - Phone:916-737-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG040844207Q00000X
261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACO4225Medicare UPIN